Semester 2: Unit 6 Exam
Match the following 1.Neurotransmission 2. Neurotransmitter 3. Regulation 4.Increased intracranial pressure A. maintenance of balance to promote an environment conducive to optimal brain function B. process of sending signals from nerve to nerve across a synapse C. pathologic condition or trauma causes pressure within the cranial vault to increase D. chemical that transmits signals from a neuron to a target cell
1. B 2. D 3. A 4. C
Cranial sutures are ossified by age_______, with no expansion of the skull after age ______
12 years 5 years
Which disease is caused by the deficiency of antidiuretic hormone? A. Acromegaly B. Diabetes insipidus C. Cushing's syndrome D. Syndrome of inappropriate antidiuretic hormone
B. Diabetes insipidus Diabetes insipidus is caused by the deficiency of antidiuretic hormone. Acromegaly and Cushing's syndrome are not associated with antidiuretic hormone; excessive production of growth hormone results in acromegaly and excessive production of adrenocorticotropic hormone causes Cushing's syndrome. Syndrome of inappropriate antidiuretic hormone occurs due to increased production of antidiuretic hormone.
Nclex question Which of the following statements are true regarding Type 2 diabetes treatment?* A. Insulin and oral diabetic medications are administered routinely in the treatment of Type 2 diabetes. B. Insulin may be needed during times of surgery or illness. C. Insulin is never taken by the Type 2 diabetic. D. Oral medications are the first line of treatment for newly diagnosed Type 2 diabetics.
B. Insulin may be needed during times of surgery or illness.
Power points, If a patient has hypothyroidism which foods will the nurse recommend the patient avoid A. Orange juice, milk products, and apples B. Kale, rutabaga, broccoli, and soy C. Cod, avocado, eggs, and prunes D. scallops, almonds, cherries
B. Kale, rutabaga, broccoli, and soy Avoid goitrogens such as: Foods that contain gluten: Bread, pasta, cereals, beer, etc. Soy foods: Tofu, tempeh, edamame beans, soy milk, etc. Cruciferous vegetables: Broccoli, kale, spinach, cabbage, etc. Certain fruits: Peaches, pears and strawberries
A nurse is collecting information about a client with type 1 diabetes who is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? Taking too much insulin Getting too much exercise Excessive emotional stress Running a fever with the flu Eating fewer calories than prescribed
Running a fever with the flu Excessive emotional stress
Which hormone is released from the pancreas? A. Oxytocin B. Prolactin C. Calcitonin D. Somatostatin
Somatostatin is a hormone produced by the pancreas that inhibits the release of insulin and glucagon. Oxytocin is a hormone produced by the posterior pituitary gland that acts on the uterus and mammary glands. Prolactin is a hormone produced by the anterior pituitary gland that targets the ovaries and mammary glands in women and testes in men. Calcitonin is a hormone produced by the thyroid gland that interacts with bone tissue.
What is released when serum blood glucose levels are low A. Insulin B. Glycogen C. Glucagon D. Lipids
C. Glucagon
Giddens Optimal ICR is dependent on
transmission of nerve impulses across neuronal synapses by neurotransmitters.
The nurse is caring for a client who has normal glucose levels at bedtime, hypoglycemia at 2am and hyperglycemia in the morning. What is this client likely experiencing? Answers: A. Dawn phenomenon B. Somogyi effect C. An insulin spike D. Excessive corticosteroids
. B, Somogyi effect The Somogyi effect is when blood sugar drops too low in the morning causing rebound hyperglycemia in the morning. The hypoglycemia at 2am is highly indicative. The Dawn phenomenon is similar but would not have the hypoglycemia at 2am.
Nclex question A 36 year old male is newly diagnosed with Type 2 diabetes. Which of the following treatments do you expect the patient to be started on initially?* A. Diet and exercise regime B. Metformin BID by mouth C. Regular insulin subcutaneous D. None, monitoring at this time is sufficient enough
A. Diet and exercise regime
A nurse is caring for a client who has a 20-year history of type 2 diabetes. The nurse should assess for what physiologic changes associated with a long history of diabetes? A. Blurry, spotty, or hazy vision B. Arthritic changes in the hands C. Hyperactive knee and ankle jerk reflexes D.Dependent pallor of the feet and lower legs
A. Blurry, spotty, or hazy vision Blurry, spotty, or hazy vision; floaters or cobwebs in the visual field; and cataracts or complete blindness can occur as a result of diabetes. Diabetic retinopathy is characterized by abnormal growth of new blood vessels in the retina (neovascularization). More than 60% of clients with type 2 diabetes have some degree of retinopathy after 20 years. Arthritic changes of the hands are not a usual complication associated with diabetes mellitus. Clients who are diabetic have peripheral neuropathy, which is characterized by hypoactive, not hyperactive, reflexes. Peripheral vascular disease is indicated by dependent rubor with pallor on elevation, not dependent pallor.
powerpoints Signs and symptoms of hypothyroidism (select all that apply) A. Cold intolerance B. Heat intolerance C. Weight gain D.Fatigue E. Slow HR F. Constipation G. HTN H. Fluid loss
A. Cold intolerance C. Weight gain D.Fatigue E. Slow HR F. Constipation Hyperthyroidism--> Heat intolerance, tachycardia, HTN, fluid loss, weight loss, exophthalmos
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees
A. Coughing B. Sneezing D. Valsalva maneuver E. Vomiting These activities can increase ICP.
Emergency treatment for hypoglycemia (select all that apply) A. Glucagon 1mg subq B. 15 grams of fast acting simple carbhoydrate C. One ampule of D50 IV push D. Administer prescribed insulin
A. Glucagon 1mg subq C. One ampule of D50 IV push 15 grams of fast acting simple carbohydrate --> treatment for hypoglycemia in a non emergent hypoglycemic event patient is unconscious
Which of the following is contraindicated in a patient with increased ICP?* A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications
A. Lumbar puncture LPs are avoided in patients with ICP because they can lead to possible brain herniation.
red-yellow lesions, with atrophic skin that becomes shiny and transparent revealing tiny blood vessels under the surface A. Necrobiosis Lipoidica Diabeticorum B. Acanthosis Nigricans C. Diabetes-related dermopathy D. Psoriasis
A. Necrobiosis Lipoidica Diabeticorum
What are the most common hormones produced in excess with hyperpituitarism? Select all that apply. A. Prolactin B. Growth hormone C. Luteinizing hormone D. Antidiuretic hormone E. Melanocyte-stimulating hormone
A. Prolactin B. Growth hormone The most common hormones produced in excess with hyperpituitarism are prolactin and growth hormone. Excessive stimulation of luteinizing hormone and antidiuretic hormone is also associated with hyperpituitarism, but less commonly than prolactin and growth hormone. Secretion of melanocyte-stimulating hormone stimulates adrenocorticotropic hormone, which indirectly stimulates the pituitary gland, thus leading to hyperpituitarism.
You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature?* A. Rectal B. Oral C. Axillary
A. Rectal This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.
Nclex question Type 1 diabetics typically have the following clinical characteristics: A. Thin, young with ketones present in the urine B. Overweight, young with no ketones present in the urine C. Thin, older adult with glycosuria D. Overweight, adult-aged with ketones present in the urine
A. Thin, young with ketones present in the urine
Causes of hypoglycemia (select all the apply) A. Insufficient insulin production B.Inadequate nutritional intake C. Excessive exercise D. Excessive counter-regulatory hormone
B, C Causes of HYPERgylcemia: Insufficient insulin production Deficient hormone signaling Excessive counter-regulatory hormone Adverse reaction to medication
Individual risk factors for stroke (name 8)
Age HTN DM Smoking Obesity Cardiovascular disease Genetics
You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is:* A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg
B. 60-100 mmHg
Nclex question Which of the following patients is at most risk for Type 2 diabetes?* A. A 6 year old girl recovering from a viral infection with a family history of diabetes. B. A 28 year old male with a BMI of 49. C. A 76 year old female with a history of cardiac disease. D. None of the options provided.
B. A 28 year old male with a BMI of 49.
Which patient below is at MOST risk for increased intracranial pressure?* A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.
B. A patient who is admitted with a traumatic brain injury. Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.
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:* A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing
B. Decerebrate posturing
Nclex question A patient with diabetes has a morning glucose of 50. The patient is sweaty, cold, and clammy. Which of the following nursing interventions is MOST important?* A. Recheck the glucose level B. Give the patient ½ cup (4 oz) of fruit juice C. Call the doctor D. Keep the patient nothing by mouth
B. Give the patient ½ cup (4 oz) of fruit juice
A small-for-gestational-age (SGA) newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respirations. With which condition are these signs associated? A. Hypervolemia B. Hypoglycemia C. Hypercalcemia D. Hypothyroidism
B. Hypoglycemia SGA infants may exhibit hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. These are not signs of hypervolemia. Hypervolemia is usually the result of excessive intravenous infusion. It is unlikely that a full-term SGA infant will need intravenous supplementation. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.
A Type 2 diabetic may have all the following signs or symptoms EXCEPT:* A. Blurry vision B. Ketones present in the urine C. Glycosuria D. Poor wound healing
B. Ketones present in the urine
External ventricular drains monitor ICP and are inserted where?* A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle
B. Lateral Ventricle External ventricular drains (also called ventriculostomy) are inserted in the lateral ventricle.
. A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?* A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.
B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine.
A newborn is admitted to the neonatal intensive care unit with a myelomeningocele. What is the priority nursing intervention during the first 24 hours? A. Using only disposable diapers for perineal care B. Placing the infant in a prone or side-lying position C. Washing the infant's genital area with an antiinfective D. Performing neurologic checks above or at the site of the lesion
B. Placing the infant in a prone or side-lying position A prone or side-lying position will prevent pressure on the sac; if the sac ruptures, infection may occur. Diapers should not be applied, because they may irritate or contaminate the sac. Antiinfectives are too caustic. Assessment of the area below, not at or above, the defect is essential to determination of motor, urinary, and bowel function.
The primary healthcare provider suspects pituitary gland dysfunction in a female client. Which diagnostic test would the primary healthcare provider suggest to the client? A. Estradiol test B. Prolactin test C. Sims-Huhner test D. Papanicolaou (Pap) test
B. Prolactin test A prolactin test is used to detect pituitary gland dysfunction that causes amenorrhea. Therefore the primary healthcare provider would suggest that the client have a prolactin test to determine if the client does or does not have any pituitary gland dysfunction. Estradiol is tested to determine functioning of the ovaries. In men, the estradiol test is used to detect testicular tumors. The Sims-Huhner test is used to evaluate the hostility of the cervix for passage of sperm from the vagina into the uterus. The Papanicolaou (Pap) test detects malignancies, particularly cervical cancer.
After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client? A. Edema at extremities B. Uneven patches of pigment loss C. Reddish-purple stretch marks on the abdomen D. "Buffalo hump" between shoulders on the back
B. Uneven patches of pigment loss Vitiligo is manifested by the presence of large patchy areas of pigment loss. This is mainly caused by primary hypofunction of the adrenal gland. Presence of edema at extremities indicates fluid and electrolyte imbalances mainly observed in a client with thyroid problems. Presence of reddish-purple stretch marks on the abdomen and "buffalo hump" between shoulders on the back of the neck often indicates excessive adrenocortical secretions.
powerpoints diabetes insipidus there is A. excessive TSH B. inadequate ADH C. inadequate TSH D. excessive ADH
B. inadequate ADH excessive ADH is SIADH
Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? A) Urine output B) Specific gravity C) Urine osmolarity D) Serum osmolarity
C) Urine osmolarity - Polydipsia and polyuria are signs of diabetes insipidus. When a water deprivation test is performed, urine osmolarity is increased dramatically from 100 to 600 mOsm (mmol)/kg in clients with central diabetes insipidus. But in nephrogenic diabetes insipidus, the urine osmolarity may not be greater than 300 mOsm (mmol)/kg. The urine output is 2 L to 20 L/day in all types of diabetes insipidus. The specific gravity is less than 1.005 in all types of diabetes insipidus and the serum osmolarity is also greater than 295 mOsm (mmol)/kg in all types of diabetes insipidus.
power points A pregnant women with without risk factors should have a glucose tolerance test done when ? A. 6-9 weeks B. 13-20 weeks C. 24-28 weeks D 29-34 weeks
C. 24-28 weeks
What other name can the nurse use for vasopressin? A. Growth hormone B. Luteinizing hormone C. Antidiuretic hormone D. Thyroid-stimulating hormone
C. Antidiuretic hormone Antidiuretic hormone is also called vasopressin. Growth hormone can be called somatotropin. Luteinizing hormone is a gonadotropin. Thyroid-stimulating hormone can be called thyrotropin.
The nurse assesses a patient who responds to nail bed pressure by exhibiting internal rotation, adduction, and flexion of the arms. The nurse assesses this response as: A. Flexion withdrawal B. Localization of pain C. Decorticate posturing D. Decerebrate posturing
C. Decorticate posturing Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawa
A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time? A. Range of expressed anger B. Extent of orientation to reality C. Degree of control over the behavior D. Determination of whether the anger is justified
C. Degree of control over the behavior Degree of control over the behavior is the most important assessment because it will influence the nurse's intervention. Depending on the extent of the client's control, the nurse may or may not need assistance. It is not the degree of anger but instead the behavior it precipitates that is important to assess. The extent of orientation to reality may or may not influence the ability to control behavior. Anger is always justifiable to the person; the determination of whether the anger is justified will not help the nurse address the client's behavior.
The process where the body produces glucose from non-carbohydrate sources A. Glycogenolysis B. Glycogenogesis C. Gluconeogenesis D. Hypogylcogenesis
C. Gluconeogenesis
The major stored form of sugar, which is typically stored in the liver and muscle cells A. Glucose B. Glucagon C. Glycogen D. Ketones
C. Glycogen
A patient has a ventriculostomy. Which finding would you immediately report to the doctor?* A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35
C. ICP 24 mmHg
Power point Which hormone is related to a rhythm that is longer than a circadian rhythm A. cortisol B. growth hormone C. LH D. Melatonin
C. LH hormones involved in mensuration are on a rhythm of typically 28 days
Program that teaches nurses and other hospital staff how to recognize signs of escalating anger that could result in a violent attack and strategies to de-escalate the situation
Crisis intervention program
Which hormones does the nurse state are released by the hypothalamus? Select all that apply. A. Follicle-stimulating hormone (FSH) B. Thyroid-stimulating hormone (TSH) C. Melanocyte-inhibiting hormone (MIH) D. Corticotropin-releasing hormone (CRH) E. Growth hormone-releasing hormone (GHRH)
C. Melanocyte-inhibiting hormone (MIH) D. Corticotropin-releasing hormone (CRH) E. Growth hormone-releasing hormone (GHRH) The hypothalamus is a small area of nerve and endocrine tissue located beneath the thalamus in the brain. MIH, CRH, and GHRH are released by the hypothalamus. FSH and TSH are released by the anterior pituitary gland.
Which condition results in elevated serum adrenocorticotropic hormone (ACTH) and urine cortisol levels? A. Diabetes insipidus B. Adrenal Cushing's syndrome C. Pituitary Cushing's syndrome D. Syndrome of inappropriate antidiuretic hormone
C. Pituitary Cushing's syndrome In pituitary Cushing's syndrome, urine cortisol and serum adrenocorticotropic hormone levels are raised. Diabetes insipidus is the result of decreased levels of antidiuretic hormone and is not associated with cortisol and ACTH levels. Adrenal Cushing's syndrome is caused by chronic steroid use, so the client will have increased urine cortisol and decreased ACTH levels. Syndrome of inappropriate antidiuretic hormone is the result of elevated levels of antidiuretic hormone and is not related with the ACTH and cortisol levels.
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?* A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning
C. Remove extra blankets and give the patient a cool bath It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).
Which is a late sign of increased intracranial pressure? A. restlessness B. confusion C. cheyne stokes D. problems answering questions
C. cheyne stokes
A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? A. "You will need to decrease your exercise." B. "An extra tablet will help your body use glucose correctly." C. "When taking medicine, your diet will not be affected by exercise." D. "No, but you should observe for signs of hypoglycemia while exercising."
D. "No, but you should observe for signs of hypoglycemia while exercising." Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia. Exercise should not be decreased because it improves glucose metabolism. An extra tablet probably will result in hypoglycemia because exercise alone improves glucose metabolism. Control of glucose metabolism is achieved through a balance of diet, exercise, and pharmacologic therapy.
A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage? A. Dry mouth B. Rigidity of neck muscles C.Fall in blood pressure upon standing D. A yellow edge around nasal discharge
D. A yellow edge around nasal discharge Nasal hypophysectomy is a surgical procedure performed to treat hyperpituitarism due to pituitary gland tumors. During postoperative care and follow-up, the appearance of light-yellow at the edge of otherwise clear nasal discharge in the dressing indicates leakage of cerebrospinal fluid (CSF). This is called the "halo sign" and is indicative of a CSF leak. Dry mouth after nasal hypophysectomy is normal because the client breathes through the mouth due to the nasal packing. Neck rigidity could be an indication of infection, such as meningitis following the surgery. A fall in blood pressure upon standing is called orthostatic hypotension and is a side effect of bromocriptine.
A nurse is caring for a client with Addison's disease. Upon assessment, which classic sign will the nurse find? A.Ecchymosis B. Hyperreflexia C. Exophthalmos D. Hyperpigmentation
D. Hyperpigmentation Hyperpigmentation, or "bronzing," is a classic sign of Addison's disease. Ecchymosis (bruise) is the discoloration of the skin due to rupture of blood vessels beneath the skin. Hyperreflexia is a sign of hypoparathyroidism. Exophthalmos is the classic sign of hyperthyroidism.
A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting-out behavior? A. Being assertive B. Responding early C. Providing choices D. Teaching relaxation
D. Teaching relaxation Once the client is agitated, teaching will not be effective and may increase the client's anxiety. Teaching relaxation techniques can be done once the client calms down. Being assertive (not aggressive) shows the client that the nurse is confident in handling the situation. This may help reduce the client's anxiety. Responding before agitation escalates makes interventions more likely to be successful. Providing choices may help the client feel less threatened and avoids a power struggle.
During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find?* A. The eyes will move in the same direction as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed position as the head is moved side to side.
D. The eyes will be in a fixed position as the head is moved side to side. The answer is D. This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign.
Nclex question What statement or statements are INCORRECT regarding Diabetic Ketoacidosis?* A. DKA occurs mainly in Type 1 diabetics. B. Ketones are present in the urine in DKA. C. Cheyne-stokes breathing can present in DKA. D. Severe hypoglycemia is a hallmark sign in DKA. E. Options 3 & 4
E. Options C & D
So How is CPP calculated?
Equation: CPP= MAP - ICP patient's mean arterial pressure (MAP) You need to know the following: BP: 90/42 ICP: 19
True or false: Work place violence can only an action of physical aggression, which is intended to control or cause
FALSE Work place violence can only an action (verbal, written, or physical aggression) which is intended to control or cause
List 5 individual risk factors for interpersonal violence
Impaired physical and/or mental health Use or misuse of substances or alcohol abuse Migration, acculturation Unemployment Economic stress
A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What common complications of diabetes might the nurse expect to identify when assessing this client? Select all that apply. Leg ulcers Loss of visual acuity Thick, yellow toenails Increased growth of body hair Decreased sensation in the feet
Leg ulcers Loss of visual acuity Thick, yellow toenails Decreased sensation in the feet
Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes? A. Ketones in the blood but not in the urine B. Glucose in the urine but not hyperglycemia C. Urine negative for ketones and hyperglycemia D. Blood and urine positive for both glucose and ketone
Urine negative for ketones and hyperglycemia
Powerpoints When assessing for impaired hormonal regulation that nurse should look for changes in A. nutritional status B. elimination habits C. sleep patterns D. activity levels E. sexual respones
all of them A. nutritional status B. elimination habits C. sleep patterns D. activity levels E. sexual respones
A 46-year-old patient with a head injury opens the 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. The nurse records the patient's Glasgow Coma Scale score as a.9. b.11. c.13. d.15.
b.11.
Nclex question Which of the following symptoms do NOT present in hyperglycemia? a. Extreme thirst b. Hunger c. Blood glucose <60 mg/dL d. Glycosuria
c. Blood glucose <60 mg/dL
What are the two hormones that are released from the posterior pituitary gland ?
oxytocin and ADH
Primary and secondary prevention for interpersonal violence
primary: awareness Secondary: screening tools such as Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Setting
ICP is normally________ in adults a sustained ICP of __________ is considered intracranial hypertension.
≤15 mm Hg ≥20 mm Hg
What is a normal CPP?
60-100 mmHg Cerebral perfusion pressure can become compromised during increased intracranial pressure. Therefore, there must be a sufficient cerebral perfusion pressure so that the brain is properly maintain. When CPP falls too low the brain is not perfused and brain tissue dies.
CSF is produced at a rate of approximately ______
20ml/hr
A 16-year-old adolescent with recently diagnosed type 1 diabetes will receive NPH insulin subcutaneously. The nurse teaches the adolescent about peak action of the drug and the risk for hypoglycemia. How many hours after NPH insulin administration does the insulin peak? 1 to 2 hours 2 to 4 hours 5 to 10 hours 4 to 12 hours
4 to 12 hours
You're maintaining an external ventricular drain. The ICP readings should be?* A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg
A. 5 to 15 mmHg Normal ICP should be 5 to 15 mmHg.
The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse?* A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal
A. 90 mmHg, normal The answer is A. CPP is calculated by the following formula: CPP=MAP-ICP. The patient's CPP is 90 and this is normal. A normal CPP is 60-100 mmHg.
A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow? A. Add extra salt to food B. Consume high-potassium foods C. Omit protein foods at each meal D. Restrict the daily intake of fluids to 1 L
A. Add extra salt to food Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to developing hyponatremia. Therefore, the addition of salt to the diet is advised. Clients with Addison disease are prone to hyperkalemia. High-potassium foods can be restricted. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism and healing. Fluids are not restricted for clients with Addison disease.
Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater
A. Brain C. Cerebrospinal Fluid D. Blood The answers are A, C, and D. Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood
A 10-year-old girl with diabetes joins the school's soccer team. Her mother is unsure whether to tell the coach of her child's condition. The mother asks the school nurse for guidance. On what information should the nurse base the response? A. Children with diabetes who participate in active sports can have episodes of hypoglycemia. B. Children may have to leave athletic teams if school authorities learn that they have diabetes. C. The school nurse will treat the child if clinical findings of hypoglycemia are recognized early. D. The coach might violate confidentiality by discussing the child's condition with other faculty members.
A. Children with diabetes who participate in active sports can have episodes of hypoglycemia. The people associated with the school who are interacting with the child should be told about the child's condition. Knowledgeable people can be alert for early signs of hypoglycemia and have snacks available for the child to help prevent a hypoglycemic episode. Forcing the child to leave the team is a form of discrimination; children with diabetes are allowed to engage in activities as long as their diabetes remains under control. The adult who is with the child when the signs of hypoglycemia first appear should be prepared to treat the child; this person may or may not be the nurse. Information about the child's health status is on a "need to know" basis; professionals are expected to honor confidentiality.
Which of the following processes have the strongest links to intracranial regulation? (Select all that apply.) A. Cognition B. Mobility C. Oxygenation D. Perfusion E.Safety
A. Cognition B. Mobility C. Oxygenation D. Perfusion Cognition, mobility, oxygenation, and perfusion have the strongest links to intracranial regulation and include processes that are essential for the nurse to consider when caring for a patient with intracranial concerns. Cognitive function is dependent on an optimally functioning brain. Mobility is frequently affected by intracranial regulation problems, with the most common example being a cerebrovascular accident. Perfusion and oxygenation are intimately involved with intracranial regulation, and without adequate perfusion and oxygenation, the brain cannot function. Other processes that may be closely related include clotting and pain, and interpersonal violence may also be a consideration. Safety refers to the prevention of injuries or freedom from accidents, both of which could be related to intracranial regulation but would not be the strongest links for the nurse to consider.
Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing
A. Decorticate posturing C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing . Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.
What are the 7 hormones the anterior pituitary secretes?
Adrenocorticotrophic hormone (ACTH)--> this leads to increased cortisol Thyroid-stimulating hormone (TSH) Luteinising hormone (LH) Follicle-stimulating hormone (FSH) Prolactin (PRL) Growth hormone (GH) Melanocyte-stimulating hormone (MSH)
The nurse correctly identifies an example of exocrine glands when stating the name of which glands? (Select all that apply.) A. Mammary B. Salivary C.Sweat D.Thyroid E. Bartholin F. Pancreas
A. Mammary B. Salivary C.Sweat E. Bartholin An endocrine gland refers to a specialized cluster of cells, tissue, or organ that produce and secrete hormones directly into the bloodstream. This distinction is important because there are also other types of glands (known as exocrine glands) that excrete other non-hormonal substances or fluids through ducts to body organs, cavities, or the skin. Examples include sweat glands, salivary glands, mammary glands, bartholin glands as examples). The thyroid and pancreas are examples of endocrine glands that secrete hormones.
A patient who has diabetes is nothing by mouth as prep for surgery. The patient states they feel like their blood sugar is low. You check the glucose and find it to be 52. The next nursing intervention would be to:* A. Notify the doctor for further orders regarding the blood sugar B. Continue to monitor the glucose C. Give the patient 3 graham crackers to eat D. None, this is a normal blood glucose reading
A. Notify the doctor for further orders regarding the blood sugar
Which hormones are secreted by the posterior pituitary gland? Select all that apply. A. Oxytocin B. Prolactin C. Corticotropin D. Antidiuretic hormone E. Melanocyte-stimulating hormone
A. Oxytocin D. Antidiuretic hormone Oxytocin and antidiuretic hormone (vasopressin) are secreted by the posterior pituitary gland. Prolactin, corticotropin, and melanocyte-stimulating hormones are secreted by the anterior pituitary gland.
Which hormone is released from the posterior pituitary gland? A. Oxytocin B. Prolactin C. Growth hormone D. Luteinizing hormone
A. Oxytocin Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.
Which glands secrete hormones that regulate metabolism of carbohydrates, proteins, and fats? Select all that apply. A. Pancreas B. Thyroid gland C. Adrenal cortex D. Adrenal medulla E. Parathyroid gland
A. Pancreas B. Thyroid gland C. Adrenal cortex The pancreas secretes insulin and glucagon, which affects the body's metabolism of carbohydrates, proteins, and fats. The thyroid gland secretes thyroid hormones T 3 and T 4 that regulate carbohydrates, proteins, and fat metabolism. Cortisol is a glucocorticoid secreted by the adrenal cortex that affects carbohydrates, proteins, and fat metabolism. Adrenal medulla secretes catecholamines, which do not affect metabolism of carbohydrates, proteins, and fats. Hormones secreted by the parathyroid gland mainly regulate calcium and phosphorus metabolism.
The nurse concludes that a client with type 1 diabetes is experiencing hypoglycemia. Which responses support this conclusion? Select all that apply. Vomiting Headache Tachycardia Cool, clammy skin Increased respirations
Headache Tachycardia Cool, clammy skin
The nurse is completing an admission assessment and identifies which findings that are most likely related to hormonal imbalances? (Select all that apply.) A. Thinning hair B. Dry skin C. Changes in pigmentation D. Malformation of fingernails E. Female facial hair F. Unsteady gait
A. Thinning hair B. Dry skin C. Changes in pigmentation D. Malformation of fingernails E. Female facial hair Many clues about hormonal balance (or imbalance) may be noted during a general inspection, particularly by a healthcare professional with a critical eye. Note the overall skin color and texture, hair texture, body posture, facial characteristics, and affect. Findings associated with one or more hormonal imbalances include unusual dryness, pigmentation, wounds, or other lesions, malformation of the fingernails, hair texture, excessive hair growth in unexpected areas (such on the face of women) or excessive hair loss are clinical findings associated with one or more hormonal imbalances. Note anxious or fidgety behavior, a flat affect or an overly animated affect, puffiness around the face, and protrusion of the eyes (exophthalmos).Notice the neck and determine if there is a thickening or enlargement that might be caused by an enlarged thyroid gland. Abnormal findings of the external genitalia (such as size, shape, color, pubic hair distribution) for the patient's age/developmental level may also reveal important clues associated with hormonal imbalance. Unsteady gait is most likely related to a neurological problem.
Deficiency in estrogen you will see (select all that apply) A. amenorrhea B. gynecomastia C. reduced bone density D. hypermenorrhea E. hot flashes
A. amenorrhea C. reduced bone density E. hot flashes Excessive→ Gynecomastia and hypermenorrhea
Power points Where is CSF found A. between arachnoid and pia mater B. between dura mater and pia mater C. between dura mater and arachnoid mater D. none of the above
A. between arachnoid and pia mater
Cushing's reflex is a late sign of increased intracranial pressure and is characterized with (select all that apply) A. bradycardia B. tachycardia C. hypertension D. widening pulse pressure
A. bradycardia C. hypertension D. widening pulse pressure
Which components make up ICP (select all that apply) A. brain tissue B. cerebrospinal fluid (CSF) C. fluid and electrolytes D. blood
A. brain tissue (80%) B. cerebrospinal fluid (CSF) (10%) D. blood (10%) ICP is normally ≤15 mm Hg; a sustained ICP of ≥20 mm Hg is considered intracranial hypertension.
Power points Which hormones follow a circadian rhythm (select all that apply) A. growth hormone B. prolactin C. LH D. epinephrine
A. growth hormone B. prolactin
Power points Most common cause of congenital hypothyroidism in newborn is: A. iodine deficiency B. pituitary adenoma C. goiter D. hashimoto's
A. iodine deficiency
Power points all of the following statements are true about CSF EXCEPT A. makes it difficult for neurotoxic substances to pass into the brain B. produced at a rate of approximately 20 mL/hour C. Found in the subarachnoid space D. Acts to cushion and provides nutrients.
A. makes it difficult for neurotoxic substances to pass into the brain Blood brain barrier--> restrictive barrier makes it difficult for neurotoxic substances to pass into the brain→ if perfusion is impaired neurotoxins may be able to cross this barrier
The nurse is reviewing the lab values for a patient in the gynocolgist office. The nurse notes that the lutenizing hormone (LH) lab is elevated. This is an example of which hormone action? A. positive feedback B. biological rhythms C. central nervous system stimulation D. negative feedback
A. positive feedback Positive feedback occurs when an increasing level of hormone triggers further elevation of hormone stimulation. The classic example of positive feedback is seen with the menstrual cycle, in which luteinizing hormone (LH) is secreted by the pituitary gland, which triggers the ovaries to secrete estradiol, which in turn stimulates the pituitary gland to secrete more LH. The secretion of some hormones is controlled by biological rhythms. One example of this is the influence of the circadian rhythm on cortisol secretion. Central nervous system stimulation occurs when an individual experiences a stressful situation, the sympathetic division of the autonomic nervous system is activated, triggering the release of epinephrine from the adrenal medulla (the fight-or-flight response). The most common type of feedback system for hormonal regulation is the negative feedback system, whereby information regarding a hormone level or the effect of a hormone is communicated back to the gland that secrets the hormone which directs the need for hormone secretion or suppression.
Who is most at risk for impaired intracranial pressure (select all that apply) A. very young B. elderly persons C. adolescents/young adults D. low income
A. very young B. elderly persons C. adolescents/young adults very young--> falls Elderly persons--> From degenerative pathologic conditions and injuries (falls) Adolescents and young adults --> From traumatic injury
When presenting a workshop on adolescent suicide, a community health nurse identifies which risk factors? Select all that apply. A.Victim of family violence B.Limited or strained family finances C. Member of a single-parent household D. Dependence on alcohol, drugs, or both E. Uncertainty related to sexual orientation F. Repeated demonstration of poor impulse control
A.Victim of family violence D. Dependence on alcohol, drugs, or both E. Uncertainty related to sexual orientation F. Repeated demonstration of poor impulse control Being a victim of family violence of any kind increases the risk of suicide. Alcohol or drug abuse is a significant factor in adolescent suicide. A concern about sexual orientation or being accepted as homosexual is a risk factor for suicide, especially among adolescents. Poor impulse control can lead to an increased tendency toward risk taking, which is a factor in suicide, especially among adolescents. Although economic problems and absence of a parent can both stress a family and its members, there is no research to support that either is a major factor in adolescent suicide.
Which statement is true regarding cortisol? A. Cortisol metabolizes free fatty acids. B. Cortisol stimulates gluconeogenesis. C. Cortisol stimulates protein synthesis. D. Cortisol levels decline in stressful conditions.
B. Cortisol stimulates gluconeogenesis. Cortisol maintains the blood glucose concentration by stimulating the liver for gluconeogenesis. Gluconeogenesis involves formation of glucose from amino acids and fatty acids. Cortisol mobilizes free fatty acids and inhibits protein synthesis. The blood levels of cortisol increase in stressful conditions.
. What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?* A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst
B. Crackles throughout lung fields Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.
After a craniotomy a child is returned to the postanesthesia care unit. What is the rationale for the nurse's positioning of the child in the semi-Fowler position? A. Cardiac workload is decreased, and oxygenation is facilitated. B. Cranial drainage is increased, thus preventing cerebral fluid accumulation. C. Subdural pressure is decreased, and recovery from anesthesia is enhanced. D. Thoracic cavity expansion is increased, and pressure on the diaphragm is reduced.
B. Cranial drainage is increased, thus preventing cerebral fluid accumulation. With the semi-Fowler position, gravity aids drainage of fluid from the head, which helps prevent cerebral edema. Although the semi-Fowler position helps decrease cardiac workload and facilitate oxygenation compared with the supine position, these are not the reasons that this position is used. Although the semi-Fowler position reduces subdural pressure, it does not enhance recovery from anesthesia. Although diaphragmatic pressure is reduced and there is thoracic cavity expansion, these are not the reasons that this position is used.
What are the functions of antidiuretic hormone (ADH)? Select all that apply. A. Controlling calcium balance B. Increasing arteriole constriction C. Increasing tubular permeability to water D. Stimulating the bone marrow to make red blood cells E. Promoting the reabsorption of sodium in the distal convoluted tubule (DCT)
B. Increasing arteriole constriction C. Increasing tubular permeability to water Antidiuretic hormone (ADH), also known as vasopressin, is a hormone released from the posterior pituitary gland. ADH increases arteriole constriction and tubular permeability to water. Calcium balance is controlled by blood levels of calcitonin and the parathyroid hormone (PTH). Erythropoietin stimulates the bone marrow to make red blood cells. Aldosterone promotes the reabsorption of sodium in the distal convoluted tubule (DCT).
The interrelationship of brain tissue, cerebrospinal fluid (CSF), and blood volume is known as A. Virchow triad B. Monro-Kellie doctrine C. Somogyi effect D. Dawn Phenomenon
B. Monro-Kellie doctrine
A school-aged child is receiving 45 units of intermediate-acting insulin at 7:00 AM and 7:00 PM. What will the nurse tell the parents regarding a bedtime snack? A. Offer a snack at bedtime if there are signs of hyperglycemia. B. Provide a bedtime snack to prevent hypoglycemia during the night. C. Withhold the snack after dinner to prevent hyperglycemia during sleep. D. Leave a snack at the bedside in case the child becomes hungry during the night.
B. Provide a bedtime snack to prevent hypoglycemia during the night. Intermediate-acting insulin peaks in 4 to 12 hours; a bedtime snack will prevent hypoglycemia during the night. Offering a snack at bedtime if there are signs of hyperglycemia is unsafe because it will intensify the hyperglycemia; if hyperglycemia is present, the child needs insulin. Bedtime snacks are recommended for people taking intermediate-acting insulin. When hypoglycemia develops, the child will be asleep; the snack should be eaten before bed.
The nurse understands that which patient factor places the patient at risk for hormonal imbalances? A. Active lifestyle B. Sedentary lifestyle C. Vitamin supplements D. High birth weight
B. Sedentary lifestyle Obesity and a sedentary lifestyle are associated with many hormonal imbalances, such as diabetes and polycystic ovarian syndrome. An active lifestyle has been suggested for prevention of hormone imbalances. Vitamin supplements and high birth weight are not associated with hormonal imbalances.
A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs? A. Lubricating the skin with baby oil B. Suctioning the oropharynx routinely C. Elevating the head of the bed 20 degrees D. Cleansing the eyes every four hours with normal saline
B. Suctioning the oropharynx routinely Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure. The nurse should intervene to correct this behavior. All the rest are correct behaviors. Lubricating the skin keeps the skin from drying, which helps prevent skin breakdown. Elevating the head of the bed promotes venous return to the heart and is used to limit increased intracranial pressure. Instilling artificial tears every two hours is the appropriate intervention. The corneal reflex may be absent in the unconscious client; a dry cornea is prone to injury.
The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier
B. Vasodilation of cerebral vessels D. Leaking proteins into the brain barrier The answers are B and D. These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).
A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client? A. Thyroxine (T 4) and x-ray films B. Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T 3) C. Thyroglobulin level and PO 2 D. Protein-bound iodine and sequential multichannel autoanalyzer (SMA)
B. Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T 3) A decreased TSH assay together with an elevated T 3 level may indicate hyperthyroidism. X-ray results will not indicate thyroid disease, and elevation of T 4 level might indicate hyperthyroidism. However, this may be a false reading because of the presence of thyroid-binding globulin (TBG) and is inadequate for diagnosis when used alone. PO 2 is not specific to thyroid disease, and the thyroglobulin level is most useful to monitor for recurrence of thyroid carcinoma or response to therapy. The results with the SMA are not specific to thyroid disease; the protein-bound iodine test is not definitive because it is influenced by the intake of exogenous iodine.
Nclex question The _____ ______ secrete insulin which are located in the _______.* A. Alpha cells, liver B. Alpha cells, pancreas C. Beta cells, liver D. Beta cells, pancreas
D. Beta cells, pancreas
What behavioral findings correspond to intimate partner violence in young adolescents? Select all that apply. A: Sexually acting out B: Attempting suicide C: Pattern of substance abuse D: Fear of certain people or places E: Preoccupation with others or one's own genitals
B: Attempting suicide C: Pattern of substance abuse Adolescent undergoing intimate partner violence may attempt suicide or have patterns of substance abuse. The behavioral findings in children undergoing sexual abuse include sexually acting out, fear of certain people or places, and a preoccupation with genitalia
The registered nurse instructs the new nurse in orientation regarding the physiologic processes of the endocrine system prior to client assessment. Which statement made by the new nurse indicates effective learning? A. "The endocrine system comprises glands with narrow ducts." B. "The endocrine system comprises salivary and lacrimal glands." C. "The hormones of the endocrine system exert their action by 'lock and key' mechanism." D. "The hormones secreted by endocrine system exert their action on all tissues they contact."
C. "The hormones of the endocrine system exert their action by 'lock and key' mechanism." The endocrine glands secrete hormones that exert their action on the target tissues by the "lock and key" mechanism. The hormones recognize and adhere only to specific receptor sites on the target tissue, like a correct key alone can open its specific lock. The glands of the endocrine system are ductless and secrete hormones that are carried via the blood circulation. Salivary and lacrimal glands are not endocrine but secretory glands. The hormones are carried via blood to various tissues, but they exert their action only on specific target tissues.
Which patient below with ICP is experiencing Cushing's Triad? A patient with the following:* A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12
C. BP 200/60, HR 50, RR 8 Cushing's reflex is a late sign of increased intracranial pressure. It is characterized with bradycardia, hypertension and a widening pulse pressure These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.
Which neurologic manifestation in a client is associated with hyperthyroidism? A. Confusion B. Hearing loss C. Exophthalmos D. Slowness of speech
C. Exophthalmos In hyperthyroidism, edema in the extraocular muscles and increased fatty tissue behind the eye leads to exophthalmos. Confusion, hearing loss, and slowness of speech are caused by hypothyroidism.
A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern? A. Flexing B. Localizing C. Extending D. Withdrawing
C. Extending Abnormal upper arm extension receives a rate of 2 because it is characteristic of decerebrate (extension) posturing. Greater injury leads to less purposeful movement. Decerebrate posturing indicates severe brain injury; the only more serious response is total lack of response. Flexing, characteristic of decorticate (flexion) posturing associated with severe brain injury, receives a rate of 3. Localizing receives a rate of 5. Withdrawing receives a rate of 4. The inability to withdraw from a painful stimulus indicates the greatest neurologic impairment.
A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion? A. Sunken eyes and loss of weight B. Uncommunicative and uninteractive with others C. Foreign bodies in the rectum, urethra, or vagina D. Strangulation marks on neck from rope burns or bruises
C. Foreign bodies in the rectum, urethra, or vagina One of the physical findings that may be required to confirm child abuse is the presence of foreign bodies in the rectum, urethra, or vagina. Weight loss and sunken eyes may be a physical finding for older adult abuse. When the abuse is related to an intimate partner, the nurse may observe strangulation marks on the neck from rope burns or bruises. Staying isolated and not communicating with others are behavioral findings that may be related to older adult abuse.
The laboratory report of a client reveals increased serum cholesterol levels. Which other finding indicates growth hormone deficiency in the client? A. Scalp alopecia B. Intolerance to cold C. Pathological fractures D. Increased urine output
C. Pathological fractures Growth hormone deficiency results in thinning of bones and increases the risk for pathological fractures. Thyrotropin deficiency results in scalp alopecia and intolerance to cold. Marked increase in the volume of urine output is a sign of diabetes insipidus caused by vasopressin deficiency.
The nurse is caring for a client with diabetes mellitus who is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. What does the nurse recognize as the only type of insulin that is compatible with intravenous solutions? A. NPH insulin B. Insulin lispro C. Regular insulin D. Insulin glargine
C. Regular insulin Regular insulin acts rapidly, is approved for IV administration, and is compatible with intravenous solutions. Insulin lispro is not compatible with intravenous solutions; it is a rapid-acting insulin. Insulin glargine is not compatible with intravenous solutions; it is a long-acting insulin. NPH insulin is not compatible with intravenous solutions; it is an intermediate-acting insulin.
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?* A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size
C. Restlessness Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.
Powepoints Which test would be most helpful in identify if there is an issue in the control organ vs the target organ A. CT with contrast B. MRI C. Stimulation/Suppression testing D. Urinalysis
C. Stimulation/Suppression testing
The nurse is assessing a female patient and is able to palpate a mass by placing his hands over the patient's throat and asking the patient to swallow. The nurse documents this finding as which of the following? A. The thyroid is normal B. The thyroid is reduced C. The thyroid is enlarged D. The pituitary gland is enlarged
C. The thyroid is enlarged An enlargement of the thyroid (goiter) or the presence of nodules are abnormal findings. If the thyroid is enlarged, the area should be auscultated for bruits, which would indicate increased vascular flow. The thyroid gland, located on the anterior neck just below the cricoid cartilage, is not particularly easy to palpate unless it is abnormally large or has nodules. The pituitary gland is assessed by CT scan. The pituitary gland located at the base of the skull and cannot be palpated.
A code ____________ ensures that resources were available to help de-escalate the situation and that no nurse or any other staff member would be alone with someone who was acting out. A. Red B. Blue C. White D. Yellow
C. White do not ever try to handle a potentially violent person on your own. Use whatever procedures your organization has put in place to defuse situations; for example, call security or call a code white
The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client? A. Cystitis B. Thin and dry skin C. Decreased bone density D. Frequent yeast infections
D. Frequent yeast infections Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen.
A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP
C. cause vasodilation and increase the ICP . An elevated carbon dioxide level (52 is high...normal 35-45) in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie hypothesis.
Which insulin should the nurse prepare for the emergency treatment of ketoacidosis? A.Glargine B.NPH insulin C.Insulin aspart D. Insulin detemir
C.Insulin aspart Insulin aspart is a rapid-acting insulin (within 10 to 20 minutes) and is used to meet a client's immediate insulin needs. Glargine is a long-acting insulin, which has an onset of 1.5 hours; for diabetic acidosis, the individual needs rapid-acting insulin. NPH insulin is an intermediate-acting insulin, which has an onset of 1 to 2 hours; for diabetic acidosis, the individual needs rapid-acting insulin. Insulin detemir is a long-acting insulin; for diabetic acidosis, the individual needs rapid-acting insulin.
A client suspected to have hyperpituitarism is sent by the primary healthcare provider to undergo a suppression test. Which laboratory value would indicate a positive result? A. 3 ng/mL B. 4 ng/mL C. 5 ng/mL D. 6 ng/mL
D. 6 ng/mL When the growth hormone level in a suppression test is above 5 ng/mL, this indicates a positive result, which means the client is suffering from hyperpituitarism. Therefore, 6 ng/mL indicates a positive suppression test. When growth hormone level falls below 5 ng/mL, this indicates a negative result, which means the client is not suffering with hyperpituitarism. Therefore, 3 ng/mL, 4 ng/mL, and 5 ng/mL indicate negative results, and the client does not have hyperpituitarism.
Dark, thick skin on the neck and skin folds; may have a similar texture to velvet is known as A. Linea alba B. Telangiectasias C.Melasma D. Acanthosis nigricans
D. Acanthosis nigricans red flag for DM
Client is admitted to the emergency department with a head injury. A computed tomography (CT) scan shows a subdural hematoma. How should the nurse interpret this finding of a subdural hematoma? A. Blood within the brain tissue B. Blood in the subarachnoid space C. Blood between the dura and the skull D. Blood between the dura mater and the arachnoid layer
D. Blood between the dura mater and the arachnoid layer A subdural hematoma refers to blood between the dura mater and the arachnoid layer of the meninges. Blood within the brain tissue is an intracerebral hematoma. Blood in the subarachnoid space is below the arachnoid and is called a subarachnoid hematoma. An epidural hematoma refers to blood between the dura and the skull.
While positioning a patient in bed with increased ICP, it important to avoid?* A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips
D. Flexion of the hips The answer is D. Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP.
A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment findings indicate that the client is unconscious with vital signs of pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription? A.Mannitol B. Dexamethasone C. Chlorpromazine D. Morphine
D. Morphine Morphine injection is contraindicated for an unconscious, neurologically impaired client because it depresses respirations. Mannitol, an osmotic diuretic, is used to reduce increased intracranial pressure. Dexamethasone, a corticosteroid antiinflammatory agent, is used to help reduce increased intracranial pressure. Chlorpromazine, an antipsychotic/neuroleptic/antiemetic, can be given safely to a neurologically impaired client for restlessness.
Which hormone promotes bone resorption in a client? A. Estrogen B. Calcitonin C. Growth hormone D. Parathyroid hormone (PTH)
D. Parathyroid hormone (PTH) When serum calcium levels are lowered, secretion of PTH increases and stimulates bones to promote osteoclastic activity, which promotes bone resorption. Estrogens stimulate osteoblastic (bone-building) activity and inhibit PTH. Calcitonin inhibits bone resorption and increases the renal excretion of calcium and phosphorus as needed to maintain balance in the body. Growth hormones secreted by the anterior lobe of the pituitary gland are responsible for increasing bone length.
While assessing the airway patency of a client after a bomb blast, the nurse suspects severe brain injury and gives a score of 7 using the Glasgow Coma Scale (GCS). Which intervention is most appropriate for the client? A. Performing the jaw-thrust maneuver B. Maintaining vascular access using a large-bore catheter C. Observing for chest wall trauma or other physical abnormalities D. Preparing for endotracheal intubation and mechanical ventilation
D. Preparing for endotracheal intubation and mechanical ventilation The most appropriate intervention for a client with a GCS score of 7 is preparing for endotracheal intubation and mechanical ventilation. The jaw-thrust maneuver is performed in a client if there is any risk of spinal injury. The use of large-bore catheters to maintain vascular access is done to perform resuscitation in traumatic conditions. Observing for chest wall trauma or other physical abnormalities may not be the appropriate intervention for a client with brain injury.
Which of the following hormonal imbalances may result in an electrolyte imbalance? A. hypothyroidism B. Cushing's disease C. Addison's disease D. insulin deficiency
D. insulin deficiency Insulin deficiency may result in electrolyte imbalances. Monitoring fluid intake and output and monitoring serum electrolytes is a central component of care. Hypothyroidism, Cushing's disease, and Addison's disease do not usually result in electrolyte imbalance.
A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon? Eat a snack before going to bed. Measure the blood glucose level between 2 AM and 4 AM. Identify whether morning symptoms are typical for hyperglycemia. Administer the prescribed bedtime insulin immediately before going to bed.
Measure the blood glucose level between 2 AM and 4 AM. During the hours of sleep, the Somogyi effect may be caused by a decline in the blood glucose level in response to too much insulin. The resulting hypoglycemia stimulates counterregulatory hormones, which precipitate lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia and ketosis. Treatment involves decreasing the evening insulin. The client should check blood glucose between 2 AM and 4 AM and if the blood glucose is less than 70, the client is having a Somogyi effect. The dawn phenomenon is characterized by the release of counterregulatory hormones in the predawn hours, precipitating hyperglycemia on awakening. Treatment involves an increase in insulin. Eating a snack before going to bed should be done when insulin is taken before sleep, but it will not help to differentiate between the Somogyi effect and the dawn phenomenon. Administering the prescribed bedtime insulin immediately before going to bed depends on the insulin regimen prescribed by the health care provider and will not help to differentiate between the Somogyi effect and the dawn phenomenon. The manifestation (symptoms) of hyperglycemia has no role in differentiating the conditions.
A client with type 1 diabetes self-administers NPH insulin every morning at 8 am. The nurse evaluates that the client understands the action of the insulin when the client identifies which time range as the highest risk for hypoglycemia? Noon to 8 pm 8 pm to noon 9 am to 10 am 10 am to 11 am
Noon to 8 pm
Which glands secrete hormones that regulate metabolism of carbohydrates, proteins, and fats? Select all that apply. Pancreas Thyroid gland Adrenal cortex Adrenal medulla Parathyroid gland
Pancreas Thyroid gland Adrenal cortex The pancreas secretes insulin and glucagon, which affects the body's metabolism of carbohydrates, proteins, and fats. The thyroid gland secretes thyroid hormones T 3 and T 4 that regulate carbohydrates, proteins, and fat metabolism. Cortisol is a glucocorticoid secreted by the adrenal cortex that affects carbohydrates, proteins, and fat metabolism. Adrenal medulla secretes catecholamines, which do not affect metabolism of carbohydrates, proteins, and fats. Hormones secreted by the parathyroid gland mainly regulate calcium and phosphorus metabolism.
A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number. _______ Total GCS score
The score is 3. The score on the GCS ranges from 3 to 15. The client's lack of response earns the minimum of one point in each of the categories: eye opening response, best verbal response, and best motor response.
Daily regular insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 am. When should the nurse monitor the client for a potential hypoglycemic reaction?
before lunch Onset 30m-1hr Peak 2-5 hrs Lasts 5-8 hrs
the patient's blood pressure is 130/88 and ICP 12. What is the patient's mean arterial pressure (MAP)?* A. 42 B. 74 C. 102 D. 88
blood pressure of 130/88 and ICP reading of 12. The answer is C. MAP is calculated by taking the DBP (88) and multiplying it by 2. This equals 176. Then take this number and add the SBP (130). This equals 306. Then take this number and divide by 3, which equal 102.
