SHOCK, SEPSIS, MODS, Burns, SPINAL CORD & PERIPHERAL NERVE PROBLEMS, Stroke, Acute Intracranial Problems, Chapter 68: Emergency and Disaster Nursing

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity b. Flaccidity c. Impaired sensation d. Hyperactive reflexes

ANS: B Lower motor neuron lesions generally cause weakness or paralysis, denervation atrophy, hyporeflexia or areflexia, and decreased muscle tone (flaccidity). Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? a. Monitor fluid and electrolyte status carefully. b. Position the patient in a high Fowler's position. c. Administer vasoconstrictors to maintain cerebral perfusion. d. Maintain physical restraints to prevent episodes of agitation.

A Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

The patient's magnetic resonance imaging revealed the presence of a brain tumor. The nurse anticipates which treatment modality? a. Surgery b. Chemotherapy c. Radiation therapy d. Biologic drug therapy

A Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for (select all that apply.)? a. Seizures b. Vision loss c. Cerebral edema d. Pituitary dysfunction e. Parathyroid dysfunction f. Focal neurologic deficits

A, B, C, D, F Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

Which conditions can lead to the development of a brain abscess h (select all that apply.)? a. Endocarditis b. Ear infection c. Tooth abscess d. Skull fracture e. Scalp laceration f. Sinus infection

A, B, C, D, F Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A, B, D, E The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia.

Which outcome validates successful treatment of​ sepsis? (Select all that​ apply.) A. Oxygen saturation remaining over​ 92% B. Urine output of 480​ mL/day C. Mean arterial pressure of 90 mmHg D. Average body temperature of 98.5°F ​(36.9°​C) E. Pale, cool, moist skin

A, C, D Treatment of sepsis not only includes treating the​ infection, but also managing symptoms. The client who has undergone successful treatment of sepsis would maintain a normal mean arterial pressure of 90​ mmHg, oxygen saturation greater than​ 90%, and a normal body temperature. These findings indicate good tissue perfusion.​ Pale, cool, moist skin indicates poor thermoregulation. Urine output should be greater than 30​ mL/hr, or 720​ mL/day.

Which clinical manifestation should the nurse recognize as an indicator of early septic​ shock? (Select all that​ apply.) A. Weakness B. Alert and oriented mental status C. Oliguria D. Warm, flushed skin E. Hypotension

A, D, E Early, or​ warm, signs of septic shock include​ weakness, hypotension, and​ warmed, flushed skin. The nurse should be cognizant of these signs in order to prevent worsening of the​ client's condition. Oliguria and changes in mental status are signs of​ late, or​ cold, septic shock.

The parents of a child undergoing diagnostic tests for an unexplained ongoing fever ask the pediatric​ nurse, "What does this word procalcitonin refer​ to?" Which detail can the nurse give​ them? (Select all that​ apply.) A. ​"Procalcitonin is a mediator in lung and systemic​ infections." B. "Procalcitonin is an ultrasonic exam​ material." C. ​"Procalcitonin is metabolite of​ calcium." D. "Procalcitonin is a marker of​ sepsis." E. "Procalcitonin is a precursor of a​ hormone."

A, D, E Procalcitonin is the precursor of the hormone​ calcitonin, a marker of​ sepsis, and a mediator in lung and systemic infections. Procalcitonin has nothing to do with calcium or ultrasound exams.

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities

A. Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

A. Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

For the patient undergoing a craniotomy, the nurse provides information about the use of wigs and hairpieces or other methods to disguise hair loss a. during pre operative teaching b. in the patient asks about their use c. in the immediate postoperative period d. when the patient expresses negative feelings about his or her appearance

A. The prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed pre operatively that the head is usually shaved in surgery while the patient is anesthetized and that methods can be used after the dressings are removed postoperatively to disguise the hair loss. In the immediate postoperative period, the patient is very ill, and the focus is on maintaining neurologic function, bur preoperatively the nurse should anticipate the patient's postoperative need for self-esteem and maintenance of appearance.

The nurse caring for a client diagnosed with urosepsis finds spider angiomas of the extremities and cool fingertips. The healthcare provider suspects disseminated intravascular coagulation​ (DIC). Which collaborative intervention should the nurse​ implement? A. Administer​ fresh-frozen plasma. B. Give total parenteral nutrition. C. Decrease intravenous​ (IV) fluids. D. Administer insulin.

A. Administer​ fresh-frozen plasma. A client with DIC is bleeding and clotting at the same time.​ Therefore, to control the​ bleeding, the healthcare provider would prescribe fresh frozen​ plasma, which contains clotting factors. Insulin is used to manage blood glucose levels in clients with diabetes. The client would receive IV fluids at a higher rate to compensate for fluid shifts. Total parenteral nutrition is used to treat​ malnutrition, not DIC.

1. The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) A. A 74-year-old with palpitations and chest pain B. A 43-year-old complaining of 7/10 abdominal pain C. A 21-year-old with multiple fractures of the face and jaw D. A 37-year-old with a misaligned left leg with intact pulses

ANS: C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life- threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year-old appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analyze (analysis) REF: 1630 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?

ANS: 27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and each arm is 9%.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?

ANS: 600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 ´ 80 ´ 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

ANS: 72 mm Hg The formula for calculation of cerebral perfusion pressure is MAP - ICP.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

ANS: D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound

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

ANS: 1200 To administer 400 mL in 20 minutes, the nurse will need to set the pump to run at 1200 mL/hr.

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate? a. Infusion of immunoglobulin b. Administration of corticosteroids c. Intubation and mechanical ventilation d. Insertion of a nasogastric (NG) feeding tube

ANS: A Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and enteral nutrition may be used later in the progression of the syndrome but are not needed now. Corticosteroids are not helpful in reducing the duration or symptoms of the syndrome.

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? A. Use tweezers to remove any remaining ticks. B. Check the vital signs, including temperature. C. Give doxycycline (Vibramycin) 100 mg orally. D. Obtain information about recent outdoor activities.

ANS: A Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release. DIF: Cognitive Level: Apply (application) REF: 1651 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate 4 times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

ANS: A Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome, and the patient will be unable to ambulate. The head and neck will not need to be stabilized after a cauda equina injury, which affects the lumbar and sacral nerve roots.

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of A. vaccine. B. atropine. C. antibiotics. D. whole blood.

ANS: A Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? A. Do you feel safe in your home? B. You should not return to your home. C. Would you like to see a social worker? D. I need to report my concerns to the police.

ANS: A The nurses initial response should be to further assess the patients situation. Telling the patient not to return home may be an option once further assessment is done. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Apply (application) REF: 1636 TOP: Nursing Process: Implementation

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider should the nurse question? a. Encourage oral fluids to 3 L/day. b. Document neurologic symptoms. c. Position patient lying on the side. d. Observe respiratory status closely.

ANS: A The patient should be maintained NPO because neuromuscular weakness increases risk for aspiration. Side-lying position is not contraindicated. Assessment of neurologic and respiratory status is appropriate.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Obtain oxygen saturation. b. Check pupil reaction to light. c. Palpate the head for hematoma. d. Assess Glasgow Coma Scale (GCS).

ANS: A Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last. DIF: Cognitive Level: Application REF: 1435-1437

Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient.

ANS: A The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse's best response? a. Respect the patient's feelings and arrange for privacy at mealtimes. b. Teach the patient to chew food on the unaffected side of the mouth. c. Offer the patient liquid nutritional supplements at frequent intervals. d. Discuss the patient's concerns with visitors who arrive at mealtimes.

ANS: A The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements may help maintain nutrition but will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, I had a temperature of 103.9 F (39.9 C) at home. The nurses first action should be to A. assess the patients current vital signs. B. give acetaminophen (Tylenol) per agency protocol. C. ask the patient to provide a clean-catch urine for urinalysis. D. tell the patient that it will 1 to 2 hours before being seen by the doctor.

ANS: A The patients pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation. DIF: Cognitive Level: Apply (application) REF: 1629 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patients core temperature is 105.4 F (40.8 C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to A. apply wet sheets and a fan to the patient. B. provide O2 at 6 L/min with a nasal cannula. C. start lactated Ringers solution at 1000 mL/hr. D. give acetaminophen (Tylenol) rectal suppository.

ANS: A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

When admitting an acutely confused patient with a head injury, which action would the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A When admitting a patient who is confused and likely to be a poor historian, the nurse would obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? A. Apply external cooling device. B. Check mental status every 15 minutes. C. Avoid the use of sedative medications. D. Rewarm if temperature is <91 F (32.8 C).

ANS: A When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Apply (application) REF: 1635 TOP: Nursing Process: Planning

A 20-year-old patient arrives in the emergency department (ED) several hours after taking 25 to 30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? A. Give N-acetylcysteine (Mucomyst). B. Discuss the use of chelation therapy. C. Start oxygen using a non-rebreather mask. D. Have the patient drink large amounts of water.

ANS: A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid).

ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

ANS: A An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit? a. A 44-year-old receiving IV antibiotics for meningococcal meningitis b. A 23-year-old who had a skull fracture and craniotomy the previous day c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

ANS: A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. DIF: Cognitive Level: Application REF: 1435-1438

A patient has a tumor in the cerebellum. Which goal would the nurse use to focus the plan of care? a. Prevent falls. b. Stabilize mood. c. Avoid aspiration. d. Improve memory.

ANS: A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.

ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6° F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

ANS: A Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time. DIF: Cognitive Level: Application REF: 1438-1440

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.

ANS: A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

ANS: A Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate. DIF: Cognitive Level: Application REF: 1430-1431

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. DIF: Cognitive Level: Application REF: 1429-1430

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual. DIF: Cognitive Level: Application REF: 1431-1433

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

ANS: A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

ANS: A The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy. DIF: Cognitive Level: Application REF: 1434-1435

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, would the nurse expect will result in new prescribed interventions? a. Pale yellow urine output of 1200 mL over the past 2 hours. b. Ventriculostomy drained 40 mL of fluid in the past 2 hours. c. Brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d. Intracranial pressure spikes to 16 mm Hg when patient is turned.

ANS: A The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.

ANS: A The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP. DIF: Cognitive Level: Application REF: 1436-1437

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

ANS: A The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? A. Remove the patients rings. B. Apply ice packs to both hands. C. Apply calamine lotion to any itching areas. D. Give diphenhydramine (Benadryl) 50 mg PO.

ANS: A The patients rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry.

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Pulse b. Heart rhythm c. Breath sounds d. Body temperature

ANS: A The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing thepulse, thenurse should look for signs of breathing. theother data will also be collected rapidly but are not as essential as determining if there is a pulse.

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first? A. A patient with a red tag B. A patient with a blue tag C. A patient with a black tag D. A patient with a yellow tag

ANS: A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Remember (knowledge) REF: 1646 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

ANS: A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED.

Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

ANS: A This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.

ANS: A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended

When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? A. Assist with endotracheal intubation. B. Insert an indwelling urinary catheter. C. Begin continuous cardiac monitoring. D. Obtain an order to restrain the patient. E. Prepare to give sympathomimetic drugs.

ANS: A, B, C Cooling can produce dysrhythmias, so the patients heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated. DIF: Cognitive Level: Apply (application) REF: 1635 TOP: Nursing Process: Planning

Which interventions will thenurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.) a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Prepare to give sympathomimetic drugs. e. Obtain a prescription for patient restraints.

ANS: A, B, C Cooling can produce dysrhythmias, so the patient's heart rhythm would be continuously monitored, and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose, so restraints are not indicated.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury? a. Drive a car with powered hand controls. b. Propel a manual wheelchair on a flat surface. c. Turn and reposition independently when in bed. d. Transfer independently to and from a wheelchair.

ANS: B The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.) a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

ANS: A, B, D, E Once the spine is stabilized, treating hypotension and bradycardia are essential to prevent further spinal cord damage. Treatment involves vasopressors (e.g., phenylephrine) to maintain BP and organ perfusion. Bradycardia may be treated with atropine. The patient with a spinal cord injury is monitored for hypothermia. Infuse fluids cautiously since hypotension is not related to fluid loss and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.) a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature

ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers. Gastrointestinal motility is decreased initially, and NG suctioning is indicated.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care? a. Teach the patient to use the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

ANS: B Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Administration of low-molecular-weight heparin d. Application of pneumatic compression devices to legs

ANS: B Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? A. Palpate extremities for bilateral pulses. B. Observe the patients respiratory effort. C. Check the patients level of consciousness. D. Examine the patient for any external bleeding.

ANS: B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patients breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. DIF: Cognitive Level: Apply (application) REF: 1630 TOP: Nursing Process: Assessment

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of A. peritoneal lavage. B. abdominal ultrasonography. C. nasogastric (NG) tube placement. D. magnetic resonance imaging (MRI).

ANS: B For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application) REF: 1632 TOP: Nursing Process: Planning

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. What intervention should the nurse anticipate? a. IV infusion of tetanus immune globulin (TIG) b. Administration of the tetanus-diphtheria (Td) booster c. Intradermal injection of an immune globulin test dose d. Initiation of the tetanus-diphtheria immunization series

ANS: B If the patient has not been immunized in the past 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? A. Insert a large-bore orogastric tube. B. Assist with intubation of the patient. C. Prepare a 60-mL syringe with saline. D. Give first dose of activated charcoal.

ANS: B In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

Which action should the nurse take when caring for a patient who develops tetanus from injectable substance use? a. Avoid use of sedatives. b. Provide a quiet environment. c. Provide range-of-motion exercises daily. d. Check pupil reaction to light every 4 hours.

ANS: B In patients with tetanus, jarring, loud noises or bright lights can precipitate painful seizures. The nurse will minimize noise and avoid shining light into the patient's eyes. Range-of-motion exercises may also stimulate the patient and cause seizures. Although the patient has a history of injectable drug use, sedative medications will be needed to decrease spasms.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

ANS: B Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side.

ANS: B Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should A. obtain a complete set of vital signs. B. obtain a Glasgow Coma Scale score. C. ask about chronic medical conditions. D. attach a cardiac electrocardiogram monitor.

ANS: B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Apply (application) REF: 1630 TOP: Nursing Process: Assessment

A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action? a. The patient reports chronic severe back pain. b. The patient has new-onset weakness of both legs. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

ANS: B The new symptoms indicate spinal cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also need nursing action but do not require intervention as rapidly as the new-onset weakness.

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action should the nurse appropriately take? a. Perform care without responding to the comments. b. Ask the patient to provide input for the plan of care. c. Tell the patient abusive language will not be tolerated. d. Reassure the patient about the competence of the nursing staff.

ANS: B The patient is demonstrating behaviors consistent with the anger phase of the grief process. The nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in addressing the patient's concerns. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

What should the nurse explain to the patient who has a T2 spinal cord transection injury? a. Total loss of respiratory function may occur. b. Function of both arms should be maintained. c. Use of the patient's shoulders will be limited. d. Tachycardia is common with this type of injury.

ANS: B The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

After change-of-shift report on the neurology unit, which patient should the nurse assess first? a. Patient with Bell's palsy who has herpes vesicles in front of the ear. b. Patient with botulism who is drooling and experiencing difficulty swallowing. c. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes. d. Patient with an abscess caused by injectable drug use who needs tetanus immune globulin.

ANS: B The patient's diagnosis and difficulty swallowing indicate the nurse should rapidly assess for respiratory distress. The information about the other patients is consistent with their diagnoses and does not indicate any immediate need for assessment or intervention.

What action should the nurse identify as most important before administering botulinum antitoxin to a patient in the emergency department? a. Obtain the patient's temperature. b. Administer an intradermal test dose. c. Document the neurologic symptoms. d. Ask the patient about an allergy to eggs.

ANS: B To assess for possible allergic reactions, the nurse should administer an intradermal test dose of the antitoxin. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin.

Which problem would the nurse expect for a patient who has a positive Romberg test result? a. Pain b. Falls c. Aphasia d. Confusion

ANS: B A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg test does not assess orientation, thermoregulation, or discomfort.

An unconscious patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider would the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure. Herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate.

Which hospitalized patient would the nurse assess first? a. A patient with a transient ischemic attack (TIA) returning from carotid duplex studies b. A patient with a brain tumor who has just arrived on the unit after cerebral angiography c. A patient with a seizure disorder who has just completed an electroencephalogram (EEG) d. A patient prepared for a lumbar puncture whose health care provider is waiting for assistance

ANS: B Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse and blood pressure and assess the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible but monitoring for hemorrhage after cerebral angiogram has a higher priority.

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits? a. "Do you have any difficulty in hearing?" b. "Are you experiencing vision problems?" c. "Are you having any trouble with your balance?" d. "Have you developed any weakness on one side?"

ANS: B Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.

ANS: B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage. DIF: Cognitive Level: Application REF: 1438-1439

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. "This type of monitoring system is complex and highly skilled staff are needed." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

ANS: B Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety. DIF: Cognitive Level: Application REF: 1438

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Assure that the patient's neck is not in a flexed position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprovan) infusion.

ANS: B Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure. DIF: Cognitive Level: Application REF: 1426 | 1435-1437 | 1436-1437

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Call the family's pastor or spiritual advisor to support them while initial care is given. d. Refer the family members to the hospital counseling service to deal with their anxiety.

ANS: B The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety. DIF: Cognitive Level: Application REF: 1438

A 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 remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

ANS: B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Application REF: 1434

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first? a. Draw blood for arterial blood gases (ABGs). b. Administer 5% hypertonic saline intravenously. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Send patient for computed tomography (CT) of the head.

ANS: B The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. DIF: Cognitive Level: Application REF: 1452-1455

A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? A. Heart rate B. Breath sounds C. Body temperature D. Level of consciousness

ANS: B The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds. DIF: Cognitive Level: Apply (application) REF: 1639 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

ANS: B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist to plan a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.

ANS: C Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses."

ANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.

ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation

Which nursing assessment would the nurse consider the priority for a patient being admitted with a brainstem infarction? a. Pupil reaction b. Respiratory rate c. Reflex reaction time d. Level of consciousness

ANS: B Vital centers that control respiration are located in the medulla and part of the brainstem. They require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

Which assessments would the nurse make to monitor a patient's cerebellar function? (Select all that apply.) a. Test for graphesthesia. b. Observe arm swing with gait. c. Perform the finger-to-nose test. d. Assess heat and cold sensation. e. Measure strength against resistance.

ANS: B, C The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.

Which nursing actions would be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) a. Monitor for photophobia. b. Observe for bleeding at the puncture site. c. Keep patient NPO until gag reflex returns. d. Check pulse and blood pressure frequently. e. Assess orientation to person, place, and time.

ANS: B, D, E Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebral angiography, the nurse should assess for bleeding at the site and bleeding that may affect pulse and blood pressure. Neuro status should be assessed often to detect a possible stroke. There is no reason to keep the patient NPO. Photophobia is not expected.

The emergency department (ED) nurse is starting targeted temperature management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Evaluate changes in heart rhythm. b. Insert a urinary catheter to drainage. c. Assess neurologic status every 2 hours. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe to cooling blanket control panel.

ANS: B, D, E Experienced LPN/VNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and insert a urinary catheter under the supervision of a registered nurse (RN). Assessment of neurologic status and evaluating changes in heart rhythm require RN-level education and scope of practice.

Family members are in the patients room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? A. Keep the family in the room and assign a staff member to explain the care given and answer questions. B. Ask the family to wait outside the patients room with a designated staff member to provide emotional support. C. Ask the family members about whether they would prefer to remain in the patients room or wait outside the room. D. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

ANS: C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurses initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Apply (application) REF: 1633 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

ANS: C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? A. Prepare to administer rabies immune globulin (BayRab). B. Assist the health care provider with suturing of the bite wounds. C. Teach the patient the reason for the use of prophylactic antibiotics. D. Keep the wounds dry until the health care provider can assess them.

ANS: C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms.

A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? A. Auscultate heart sounds. B. Palpate peripheral pulses. C. Auscultate breath sounds. D. Check pupil reaction to light.

ANS: C Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patients admission diagnosis.

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. What initial intervention should the nurse perform? a. Suction the patient's nasopharynx. b. Notify the patient's health care provider. c. Push upward on the epigastric area as the patient coughs. d. Encourage incentive spirometry every 2 hours during the day.

ANS: C Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient's ability to mobilize secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. The health care provider should be notified if airway clearance interventions are not effective or additional collaborative interventions are needed.

What action would help the nurse evaluate outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia? a. Inquire if the patient is doing daily facial exercises. b. Question if the patient is using an eye shield at night. c. Ask the patient about social activities with family and friends. d. Observe the patient chewing with the unaffected side of the mouth.

ANS: C Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating if the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

Which assessment finding in a patient with a spinal cord tumor requires immediate action by the nurse? a. Depression about the diagnosis b. Anxiety about scheduled surgery c. Decreased ability to move the legs d. Back pain that worsens with coughing

ANS: C Decreasing sensation and leg movement indicates spinal cord compression, an emergency that will require rapid action (such as surgery) to prevent paralysis. The other findings will require nursing action but are not emergencies.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient's sacral area skin is reddened. b. The patient reports severe pain in the feet. c. The patient is continuously drooling saliva. d. The patient's blood pressure (BP) is 150/82 mm Hg.

ANS: C Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? A. I will take salt tablets when I work outdoors in the summer. B. I should take acetaminophen (Tylenol) if I start to feel too warm. C. I should drink sports drinks when working outside in hot weather. D. I will move to a cool environment if I notice that I am feeling confused.

ANS: C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Apply (application) REF: 1636 TOP: Nursing Process: Evaluation

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed antiemetic. c. Assess the blood pressure (BP). d. Notify the health care provider.

ANS: C The BP should be assessed immediately when a patient with an injury at the T6 level or higher reports a headache. This will help determine if autonomic hyperreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated if autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. What should the nurse identify as the most appropriate action at this phase of rehabilitation? a. Remind the patient about the importance of independence in daily activities. b. Tell the spouse to stop helping because the patient can perform activities independently. c. Develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. Recognize that it is important for the spouse to be involved in the patient's care and encourage participation.

ANS: C The best action by the nurse will be to involve all parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to believe their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia? a. Visual problems caused by ptosis. b. Poor appetite caused by loss of taste. c. Triggers leading to facial discomfort. d. Weakness on the affected side of the face.

ANS: C The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to complete? a. Determining level of consciousness b. Checking strength of the extremities c. Observing respiratory rate and effort d. Monitoring the cardiac rate and rhythm

ANS: C The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will be included in nursing care, but they are not as important as respiratory assessment.

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which action should the nurse include in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to verify the position of the right leg

ANS: C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost in the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel

ANS: C A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are a good source of potassium, but are not high in protein and calories

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.

ANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status

A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Use a cooling blanket to lower temperature. c. Swab the nasopharyngeal mucosa for cultures. d. Give acetaminophen (Tylenol) 650 mg PO.

ANS: C Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. Which condition would the nurse suspect as a likely cause of these findings? a. Cerebellar injury b. A brainstem lesion c. Frontal lobe damage d. A temporal lobe lesion

ANS: C Expressive speech (ability to express the self in language) is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour

ANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL

ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

ANS: C 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 withdrawal. DIF: Cognitive Level: Comprehension REF: 1429-1430

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP.

ANS: C The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take. DIF: Cognitive Level: Analysis REF: 1426

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

ANS: C The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour

Which item would the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? a. Sensation on the left side of the body b. Reasoning and problem-solving ability c. Ability to understand written and oral language d. Voluntary movements on the right side of the body

ANS: C The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment? a. Tests for light touch before testing for pain. b. Has the patient close the eyes during testing. c. Asks the patient if the instrument feels sharp. d. Uses an irregular pattern to test for intact touch.

ANS: C When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? A. Continuously monitor heart rhythm. B. Check neurologic status every 2 hours. C. Place cooling blankets above and below patient. D. Give acetaminophen (Tylenol) 650 mg per nasogastric tube. E. Insert rectal temperature probe and attach to cooling blanket control panel.

ANS: C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87 F (30.6 C), which assessment indicates that the nurse should discontinue active rewarming? A. The patient begins to shiver. B. The BP decreases to 86/42 mm Hg. C. The patient develops atrial fibrillation. D. The core temperature is 94 F (34.4 C).

ANS: D A core temperature of 89.6 F to 93.2 F (32 C to 34 C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Apply (application) REF: 1640 TOP: Nursing Process: Assessment

Which nursing action for a patient with Guillain-Barré syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling artificial tears b. Assessing for bladder distention c. Administering bolus enteral nutrition d. Performing passive range of motion to extremities

ANS: D Assisting a patient with movement is included in UAP education and scope of practice. Administration of enteral nutrition, administration of ordered medications, and assessment are skills requiring more education and expanded scope of practice, and the RN should perform these skills.

A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving A. tetanus immunoglobulin (TIG) only. B. TIG and tetanus-diphtheria toxoid (Td). C. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. D. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

ANS: D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Apply (application) REF: 1635 TOP: Nursing Process: Planning

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? A. A patient with no pedal pulses. B. A patient with an open femur fracture. C. A patient with bleeding facial lacerations. D. A patient with paradoxic chest movements.

ANS: D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? a. "You may be able to prevent Bell's palsy by doing facial exercises regularly." b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "Call the doctor if you experience pain or develop herpes lesions near the ear."

ANS: D Pain or herpes lesions near the ear may indicate the onset of Bell's palsy, and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patients left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? A. Send blood to the lab for a complete blood count. B. Assess further for a cause of the decreased circulation. C. Finish the airway, breathing, circulation, disability survey. D. Start normal saline fluid infusion with a large-bore IV line.

ANS: D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life- threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Apply (application) REF: 1630 TOP: Nursing Process: Implementation

A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first? A. Obtain the patients vital signs. B. Obtain a baseline complete blood count. C. Decontaminate the patient by showering with water. D. Brush off any visible powder on the skin and clothing.

ANS: D The initial action should be to protect staff members and decrease the patients exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead any/all visible powder should be brushed off. The other actions can be done after the decontamination is completed.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

ANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

A patient being admitted with bacterial meningitis has a temperature of 102.5F (39.2C) and a severe headache. Which prescribed intervention would the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

ANS: D Antibiotic therapy would be started quickly in bacterial meningitis, but cultures must be done before antibiotics are started. After the cultures are done, the antibiotic would be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

ANS: D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit? a. Monitor cerebrospinal fluid color hourly. b. Document intracranial pressure every hour. c. Turn and reposition the patient every 2 hours. d. Check capillary blood glucose level every 6 hours.

ANS: D Experienced NAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN. DIF: Cognitive Level: Application REF: 1442

A patient with suspected meningitis is scheduled for a lumbar puncture. What action would the nurse take before the procedure? a. Enforce NPO status for 4 hours. b. Transfer the patient to radiology. c. Administer a sedative medication. d. Help the patient to a lateral position.

ANS: D For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood

ANS: D H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). What new finding indicates that the nurse needs to notify the health care provider immediately? a. O2 saturation of 93% b. Respirations of 20 breaths/min c. Green nasogastric tube drainage d. Increased jugular venous distention

ANS: D Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93%, and green nasogastric tube drainage are within normal limits.

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure

ANS: D Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration. DIF: Cognitive Level: Application REF: 1432-1433

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)

ANS: D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids

After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. position the bed flat and log roll the patient. b. cluster nursing activities to allow longer rest periods. c. turn and reposition the patient side to side every 2 hours. d. perform range-of-motion (ROM) exercises every 4 hours.

ANS: D ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness. DIF: Cognitive Level: Application REF: 1450-1451

Which test would the nurse anticipate discussing with a patient who has a possible seizure disorder? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

ANS: D Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light

ANS: D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation. DIF: Cognitive Level: Analysis REF: 1432-1433 | 1437-1438

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94 degrees

ANS: D The nurse would discontinue active rewarming once the patient's core temperature reaches 90 to 95F (32.2 to 35C). Dysrhythmias, hypotension, and shivering may occur during rewarming, and should be treated but are not an indication to stop rewarming the patient.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

ANS: D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

ANS: D The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary. DIF: Cognitive Level: Application REF: 1440-1441

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "I bet my boyfriend won't even want to look at me anymore." d. "Do you think dark beige makeup foundation would cover this scar on my cheek?"

ANS: D The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion

n which order should the nurse perform the following actions for a patient admitted to the emergency department with possible C5 spinal cord trauma? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

ANS:D, C, B, A, E The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

Answer: C, D, A, B Rationale: The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed. b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin). c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled. d. A 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due.

Answer: a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed. Rationale: tPA needs to be infused within the first few hours after stroke symptoms start to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? a. Tachypnea b. Bradycardia c. Hypotension d. Narrowing pulse pressure

B Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

Answer: a. Apply intermittent pneumatic compression stockings. Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities, such as coughing and sitting up, that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? a. Ask questions that the patient can answer with "yes" or "no." b. Develop a list of words that the patient can read and practice reciting. c. Have the patient practice her facial and tongue exercises with a mirror. d. Prevent embarrassing the patient by answering for her if she does not respond.

Answer: a. Ask questions that the patient can answer with "yes" or "no." Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Risk for aspiration. b. Impaired skin integrity. c. Impaired physical mobility. d. Disturbed sensory perception.

Answer: a. Risk for aspiration. Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The diseased portion of the artery is replaced with a synthetic graft." b. "The obstructing plaque is surgically removed from inside an artery in the neck." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon flattens the plaque."

Answer: b. "The obstructing plaque is surgically removed from inside an artery in the neck." Rationale: In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The response beginning, "The diseased portion of the artery is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient? a. tPA b. Aspirin c. Warfarin d. Nimodipine

Answer: b. Aspirin Rationale: After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

Answer: b. Assist the patient onto the bedside commode every 2 hours. Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection and skin breakdown.

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)? a. Monitor and record the blood pressure daily. b. Call the health care provider if stools are tarry. c. Clopidogrel will dissolve clots in the cerebral arteries. d. Clopidogrel will reduce cerebral artery plaque formation.

Answer: b. Call the health care provider if stools are tarry. Rationale: Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

Answer: b. Check the respiratory rate and effort. Rationale: The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

Answer: b. The patient has difficulty speaking. Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure.

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient reports having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

Answer: b. The patient's blood pressure (BP) is 90/50 mm Hg. Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

Answer: c. Administer the prescribed short-acting insulin. Rationale: Administration of subcutaneous medications is included in LPN/VN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? a. Order a varied pureed diet. b. Assess the patient's appetite. c. Assist the patient into a chair. d. Offer the patient a sip of juice.

Answer: c. Assist the patient into a chair. Rationale: The patient should be as upright as possible before attempting to feed to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

Answer: c. Assist the patient to eat with the right hand. Rationale: Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC). b. Chest radiograph (chest x-ray). c. Computed tomography (CT) scan. d. 12-Lead electrocardiogram (ECG).

Answer: c. Computed tomography (CT) scan. Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

What concern should the nurse anticipate for a patient who had a right hemisphere stroke? a. Right-sided hemiplegia. b. Speech-language deficits. c. Denial of deficits and impulsiveness. d. Depression and distress about disability.

Answer: c. Denial of deficits and impulsiveness. Rationale: The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the patient refused the aspirin. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

Answer: c. Explain that the aspirin is ordered to decrease stroke risk. Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? a. Cerebral aneurysm clipping. b. Heparin intravenous infusion. c. Oral low-dose aspirin therapy. d. Tissue plasminogen activator (tPA).

Answer: c. Oral low-dose aspirin therapy. Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

11. Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

Answer: c. Place needed objects on the patient's left side. Rationale: During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take? History: * Well controlled type 2 diabetes for 10 years * Married 45 years; spouse has a heart failure and chronic obstructive pulmonary disease Physical Assessment: * Oriented to time, place, person * Speech clear * Minimal left leg weakness Physical/Occupational Therapy * Uses cane with walking * Spouse does household cleaning and cooking and assists patient with bathing and dressing a. Teach about preventing hypoglycemia. b. Begin processes to obtain a wheelchair. c. Provide support to the spouse caregiver. d. Remind the patient to take prescribed medications.

Answer: c. Provide support to the spouse caregiver. Rationale: The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should take appropriate actions to provide support to the souse caregiver. The data about the control of the patient's diabetes indicates that hypoglycemia and medication adherence are not a current concern.

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Begin tissue plasminogen activator (tPA) intravenously per protocol.

Answer: c. Start a labetalol drip to keep BP less than 140/90 mm Hg. Rationale: Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

Answer: c. The patient reports that symptoms began with a severe headache. Rationale: A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

Answer: c. The patient's usual blood pressure (BP) is 170/94 mm Hg. Rationale: Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? a. Dysphasia. b. Confusion. c. Visual deficits. d. Poor judgment.

Answer: c. Visual deficits. Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? a. Impulsive behavior. b. Right-sided neglect. c. Hyperactive left-sided tendon reflexes. d. Difficulty comprehending instructions.

Answer: d. Difficulty comprehending instructions. Rationale: Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? a. Use a calm voice to ask the patient to stop the crying behavior. b. Explain to the family that depression is normal following a stroke. c. Have the family members leave the patient alone for a few minutes. d. Teach the family that emotional outbursts are common after strokes.

Answer: d. Teach the family that emotional outbursts are common after strokes. Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control. Asking the patient to stop will lead to embarrassment.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

Answer: d. The patient has atrial fibrillation and takes warfarin (Coumadin). Rationale: The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

The nurse is assessing a client for septic shock. Which assessment finding supports this​ diagnosis? A. Oxygen​ saturation, 92% B. Blood​ pressure, 110/72 mmHg C. Central venous pressure​ (CVP), 1 mmHg D. Pulse, 60​ beats/min

C. Central venous pressure​ (CVP), 1 mmHg When assessing a client with​ sepsis, the nurse monitors the​ client's hemodynamic status with a CVP intravenous line or pulmonary artery catheter. Normal CVP is 2-8mmHg and is decreased with septic shock. The other vital signs are within normal limits.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? a. Surgical endarterectomy. b. Transluminal angioplasty. c. Intravenous heparin drip administration. d. Tissue plasminogen activator (tPa) infusion.

Answer: d. Tissue plasminogen activator (tPa) infusion. Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

During admission of a patient with a severe head injury to the emergency department the nurse places the highest priority on assessment for a. Patency of airway b. Presence of neck injury c. Neurologic status with Glasgow coma scale d. Cerebrospinal fluid leakage from the ears or nose

Correct answer: a Rationale: The nurse's initial priority in the emergency management of a patient with a severe head injury is to ensure that the patient has a patent airway.

A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? a. Test the drainage for the presence of glucose. b. Apply a loose gauze pad under the patient's nose. c. Place the patient in a modified Trendelenburg position. d. Ask the patient to gently blow the nose to clear the drainage.

B Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.

Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated ICP causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like _______________________?

B Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury.

Which client requires priority assessment for the development of septic​ shock? (Select all that​ apply.) A. A client with latex allergies B. A client admitted for a nonhealing surgical wound C. A client admitted with chronic renal failure D. A client with an indwelling urinary catheter E. A client being treated for pneumonia

B, C, D, E Clients with the following portals of entry are at risk of infections that may lead to​ sepsis: those with​ catheterizations; those undergoing respiratory​ therapies; and those with peptic​ ulcers, ruptured​ appendix, peritonitis, surgical​ wounds, intravenous​ lines, decubitus​ ulcers, burns, and traumas. Clients with pneumonia are at higher risk of sepsis. Other clients at risk of developing sepsis related to infections are those who are​ hospitalized, have debilitating chronic​ illnesses, have poor nutritional​ status, have had an invasive procedure or​ surgery, and are older adults or immunocompromised.

Which diagnostic test result would the nurse expect to find for a client with septic​ shock? (Select all that​ apply.) A. Increased partial pressure of​ oxygen, arterial ​(PaO2​) B. Decreased serum pH level C. Normal WBC count D. Increased neutrophil count E. Decreased blood urea nitrogen​ (BUN) and creatinine levels

B, D Septic shock causes a decrease in pH​ (indicating acidosis), a decrease in PaO2 and total oxygen​ saturation, and an increase in PaCO2. WBC count decreases as cells are​ destroyed, and increased neutrophils and monocytes indicate acute bacterial infection. Renal function declines as reduced perfusion and microclotting damage the small renal arterioles. As perfusion of the kidneys is decreased and renal function is​ reduced, the BUN and creatinine levels​ increase, as do urine specific gravity and osmolality.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? a. Judgment b. Eye opening c. Abstract reasoning d. Best verbal response e. Best motor response f. Cranial nerve function

B, D, E The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular/decreased respiration, increased blood pressure c. increased pulse, decreased respiration, increased blood pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

A patient with intracranial pressure monitoring has a pressure of 12mm Hg. The nurse understands that this pressure reflects a. A severe decrease in cerebral perfusion pressure b. An alteration in the production of cerebrospinal fluid c. The loss of autoregulatory control of intracranial pressure d. A normal balance between brain tissue, blood and cerebrospinal fluid

Correct answer: d Rationale: Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

B. Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11

B. no opening of eyes = 1 incomprehensible words= 2 flexion withdrawal = 4 Total = 7

The nurse is caring for several hospitalized clients. Which client requires priority assessment for​ sepsis? A. A client with gastroesophageal reflux disease​ (GERD) who is not allowed to eat or drink​ (NPO) B. A client with a urinary catheter and a temperature of 101.5°F ​(38.6°​C) C. A client with a nonruptured appendix and stable vital signs D. A client with a history of myocardial infarction​ (MI) and blood pressure of​ 130/90 mmHg

B. A client with a urinary catheter and a temperature of 101.5°F ​(38.6°​C) Indwelling catheters along with a temperature of​ 101.5°F (38.6°C) indicate that the client may be developing septicemia. The client with GERD who is NPO is not at risk for septicemia. A ruptured​ appendix, not a nonruptured​ appendix, would place the client at risk of septicemia. The client with a history of MI and an elevated blood pressure requires close monitoring but not for septicemia.

The nurse is assessing an acutely ill client diagnosed with septic shock. The nurse finds the client has developed purpura. Which condition should the nurse suspect that the client has​ developed? A. Acute respiratory distress syndrome​ (ARDS) B. Disseminated intravascular coagulation​ (DIC) C. Influenza D. Renal failure

B. Disseminated intravascular coagulation​ (DIC) DIC is characterized by simultaneous bleeding and clotting throughout the vasculature. Sepsis injures blood​ cells, causing platelet aggregation and decreased bloodflow. As a​ result, blood clots form throughout the microcirculation. The clotting slows circulation further while stimulating excess fibrinolysis. As the​ body's stores of clotting factorsare​ depleted, generalized bleeding begins. Purpura or spider angiomas are often seen on the​ client's skin. Influenza is a cause of sepsis. Renal failure is evidenced by decreased urinary output. Respiratory failure is manifested by tachypnea and dyspnea as well as arterial blood gas changes.

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

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

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased, and the blood pressure is 92/68 mm Hg. The nurse suspects which stage of shock based on this data? A. STAGE 1 B. STAGE 2 C. STAGE 3 D. STAGE 4

B. STAGE 2 Rationale:Shock is categorized by four stages. Stage 1 is characterized by restlessness, increased heart rate, cool and pale skin, and agitation. Stage 2 is characterized by a cardiac output that is less than 4 to 6 liters per minute, systolic blood pressure of less than 100 mm Hg, decreased urinary output, confusion, and cerebral perfusion pressure that is less than 70 mm Hg. Stage 3 is characterized by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4 is characterized as unresponsiveness to vasopressors, profound hypotension, slowed heart rate, and multiple organ failure. Most often, the client will not survive.

When assessing the body function of a patient with increased ICP, the nurse should initially assess a. corneal reflex testing b. extremity strength testing c. pupillary reaction to light d. circulatory and respiratory status

D. Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation).

A 5-year-old child arrives at the emergency department, and the child's parents state that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? a. nausea b. irritability c. headache d. bradycardia

BRADYCARDIA Rationale:Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

A 68-yr-old man with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? a. Codeine b. Phenytoin (Dilantin) c. Ceftriaxone (Rocephin) d. Acetaminophen (Tylenol)

C Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? a. Seizure disorders may occur in weeks or months. b. The family will be unable to cope with role reversals. c. There are often residual changes in personality and cognition. d. Referrals will be made to eliminate residual deficits from the damage.

C In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? a. High blood flow to the brain b. Normal intracranial pressure c. Impaired blood flow to the brain d. Adequate autoregulation of blood flow

C Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80 mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? a. Serum potassium and serum sodium levels b. Urine osmolality and urine specific gravity c. Absolute neutrophil count and platelet count d. Cerebrospinal fluid pressure and cell count

C Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be greater than 1500/ìL and platelet count greater than 100,000/ìL.

The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? a. Document the ICP reading in the chart. b. Determine if the patient has a headache. c. Assess the patient's level of consciousness. d. Position the patient with head elevated 60 degrees.

C The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? a. Administer IV mannitol b. Ventilator use to hyperoxygenate the patient c. Use strict aseptic technique with dressing changes. d. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

C The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

The earliest sign of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas measurement results reveal a a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 50 mm Hg d. PaCO2 of 30 mm Hg

C. A PaO2 of 50 mm Hg reflects a hypoxemia that may lead to further decreased cerebral perfusion and hypoxia and must be corrected. The pH of SaO2 are within normal range, and a PaCO2 of 30 mm Hg reflects acceptable value for the patient with increased ICP

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

C. If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor CNS depressants would be indicated.

CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by a. assessing for nystagmus b. testing the corneal reflex c. testing pupillary reaction to light d. testing for oculocephalic (doll's eye) reflex

C. One of the functions of CN III, the oculomotor nerve, is pupillary constriction, and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII, and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associatted with specific lesions or chemical toxicities and is not a definitive sign of ICP.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge for the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

C. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required. There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.37 mmol/L). The nurse would prepare to administer which medication next? A. ampule of 50% dextrose B. NPH subq C. IV fluids containing dextrose D. phenytoin for the prevention of seizures

C. IV fluids containing dextrose Rationale:Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (13.9 to 16.7 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (13.9 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. Administering codeine for relief of head and neck pain b. Controlling fever with prescribed drugs and cooling techniques c. Keeping the room dark and quiet to minimize environmental stimulation d. Maintain the patient on strict bed rest with the head of the bed slightly elevated

Correct answer: b Rationale: Fever must be vigorously managed because it increases cerebral edema and the frequency of seizures. Neurologic damage may result from an extremely high temperature over a prolonged period. Acetaminophen or aspirin may be used to reduce fever; other measures, such as a cooling blanket or tepid sponge baths with water, may be effective in lowering the temperature.

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. Keep the head of the bed flat b. Elevate the HOB by 30 degrees c. Maintain pt on the left side with the head supported on a pillow d. Use a continuous rotation bed to continuously change patient position

Correct answer: b Rationale: The nurse should maintain the patient with abnormal ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. The nurse should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevation in ICP. Elevation of the head of the bed also reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system and jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. The effects of elevation of the head of the bed on the ICP and CPP must be evaluated carefully.

Vasogenic cerebral edema increases intracranial pressure by A. Shifting fluid in the gray matter B. Altering the endothelial lining of the cerebral capillaries C. Leaking molecules from the intercellular fluid to the capillaries D. Altering the osmotic gradient flow into the intravascular component

Correct answer: b Rationale: Vasogenic cerebral edema occurs mainly in the white matter. It is caused by changes in the endothelial lining of cerebral capillaries.

The nurse is alerted to a possible acute subdural hematoma in the patient who a. Has linear skull fracture crossing a major artery b. Has focal symptoms of brain damage with no recollection of a head injury c. Develops decreased level of consciousness and a headache within 48 hrs of a head injury d. Has an immediate loss of consciousness with brief lucid interval followed by dereasing level of consciousness

Correct answer: c Rationale: An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression in elevated ICP and include decreasing level of consciousness and headache

The nurse on clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued vomiting

Correct answer: c Rationale: The patient with meningitis should be seen first; patients with meningitis must be observed closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second; although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? a. Free water should be avoided. b. Sodium restrictions can be managed. c. Dehydration can be better avoided with feedings. d. Malnutrition promotes continued cerebral edema.

D A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Excess intravenous fluid administration will also increase cerebral edema.

A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? a. Serum sodium of 120 mEq/L b. Urine specific gravity of 1.001 c. Fasting blood glucose of 80 mg/dL d. Serum osmolality of 290 mOsm/kg

D Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? a. Tonic spasms of the legs b. Curling in a fetal position c. Arching of the neck and back d. Resistance to flexion of the neck

D Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

Metabolic and nutritional needs of the patient with increased ICP are best met with a. enteral feedings that are low in sodium b. the simple glucose available in D5W IV solutions c. a fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate

D. A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

D. An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops over weeks or months

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? a. Increased heart rate and increased blood pressure b. Increased heart rate and decreased blood pressure c. Decreased heart rate and increased blood pressure d. Decreased heart rate and decreased blood pressure

D. Rationale: Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure.

Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP

D. The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

The nurse is caring for a client with a diagnosis of a urinary tract infection (UTI). The client has begun to become hypotensive, edematous, and oliguric, and has a prolonged capillary refill time. What would the nurse do first? a. administer prescribed diuretic b. administer ABX c. Administer IV bolus d. contact HCP

D. CONTACT HCP Rationale:The assessment data gathered by the nurse indicate a need to contact the PHCP, as there has been a substantial change in client status. If sepsis diagnostic criteria are not recognized and interventions implemented, the client may go into septic shock. These findings are not anticipated and do not indicate an active infection. Although a bolus of IV fluid may be prescribed, the first action needs to be to contact the PHCP.

The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What would the nurse anticipate to promote during the bowel retraining program? A. SUFFICIENTLY LOW WATER CONTENT IN STOOL B. LOW INTESTINAL ROUGHAGE THAT PROMOTES EASIER DIGESTION C. CONSTRICTION OF THE ANAL SPHINCTER BASED ON VOLUNTARY CONTROL D. STIMULATION OF THE PARASYMPATHETIC REFLEX CENTER AT THE S1-S4 LEVEL IN THE SPINAL CORD

D. STIMULATION OF THE PARASYMPATHETIC REFLEX CENTER AT THE S1-S4 LEVEL IN THE SPINAL CORD Rationale:The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.

The health care provider prescribes the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain blood and urine cultures. b. Give vancomycin by IV infusion. c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Administer oxygen to keep O2 saturation above 95%.

E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? a. meningitis b. spinal cord injury c. intracranial bleeding d. decreased cerebral blood flow

MENINGITIS Rationale:Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Rationale:Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

Which patient should the nurse assess first after receiving change-of-shift report? a. A 30-yr-old patient who has a distended abdomen and tachycardia b. A 60-yr-old patient whose ileostomy has drained 800 mL over 8 hours c. A 40-yr-old patient with ulcerative colitis who had six liquid stools in 4 hours d. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool

a. A 30-yr-old patient who has a distended abdomen and tachycardia The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient's urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Use norepinephrine to keep systolic BP above 90 mm Hg.

a. Administer furosemide (Lasix) 40 mg IV. Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock need large amounts of fluid replacement. If the patient is still hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.) a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

The nurse is caring for a client with systemic inflammatory response syndrome (SIRS) related to bacterial pneumonia. Which interventions would be most appropriate for this client? Select all that apply. a. ECG b. fluid replacement c. frequent ambulation d. ABX e. VTE prophy

a. ECG b. fluid replacement d. ABX e. VTE prophy Rationale:Because SIRS is a systemic inflammatory response, several body systems may be involved that are unrelated to the original infection. It is important for the interventions to center on monitoring, restoring tissue perfusion, fluid volume, and correcting the underlying cause of infection. Frequent ambulation is an inappropriate intervention because of the systemic inflammatory response and the need for rest to assist in healing.

The nurse caring for a client suspected of being in hypovolemic shock is trying to anticipate treatment and management interventions. What plan is most appropriate for this client? Select all that apply. a. Oxygen administration b. Mental status checks every 15 minutes c. Further assessment to confirm the type of shock d. High-dose diuretics to minimize fluid accumulation e. Laboratory blood draws every 30 minutes to trend abnormal values

a. Oxygen administration b. Mental status checks every 15 minutes c. Further assessment to confirm the type of shock Rationale:The avenues of treatment and management for hypovolemic shock encompass varying levels of complexity and acuity, and each treatment plan will depend on what type of shock the client is experiencing; thus further assessment is needed to confirm hypovolemic shock. Oxygen is an important intervention to ensure tissue perfusion. Mental status checks are also important to monitor for any deterioration in the client's condition. High-dose diuretics would worsen hypovolemic shock and every 30 minute blood draws are not necessary.

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

a. Skin cool and clammy

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated.

a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may need insulin because stress and high-calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.

A client develops an anaphylactic reaction after receiving morphine. The nurse would plan to institute which actions? Select all that apply. a. administer O2 b. assess resp status c. document event, interventions, client response d. keep pt supine regardless of BP e. leave to contact HCP f. start IV infusion of D5W & 500 mL bolus

a. administer O2 b. assess resp status c. document event, interventions, client response Rationale:An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the PHCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal.

Which nursing interventions are essential to perform when caring for a client with a severe anaphylactic reaction? Select all that apply. a. administer o2 b. maintain patent airway c. prescribed IV fluids d. monitor for hypotension e. administer corticosteroids f. educate family on avoiding allergens

a. administer o2 b. maintain patent airway c. prescribed IV fluids d. monitor for hypotension e. administer corticosteroids Rationale:An anaphylactic reaction must be treated immediately. If left untreated, the client could go into shock. Nursing actions for management and treatment include assessing and maintaining a patent airway, administering oxygen, starting IV fluids with normal saline, administering prescribed medications that can help decrease the systemic effects, and monitoring for signs of shock, which include severe hypotension. Client and family education during the acute phase is inappropriate and can wait until the client is more stable.

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse plans for which intervention as the priority for this client? a. dopamine b. whole blood c. IV fluids d. PRBCs

a. dopamine Rationale:The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.

A client with systemic inflammatory response syndrome (SIRS) is being monitored in an intensive care unit. The client is being mechanically ventilated for a secondary complication of acute respiratory distress syndrome (ARDS). The nurse is planning care for the client. What interventions would be best to include? Select all that apply. a. monitor urinary output b. implement continuous ECG monitoring c. reposition every 2 hours d. allow pt to eat to promote healing e. follow improvement with frequent chest xrays

a. monitor urinary output b. implement continuous ECG monitoring c. reposition every 2 hours Rationale:Nursing interventions appropriate for a mechanically ventilated client with SIRS and ARDS should focus on restoring tissue perfusion and circulating volume, and correcting lung compliance. Monitoring urinary output and continuous ECG are important indicators of both tissue perfusion and circulating volume. Repositioning the client will help decrease the risk of pressure ulcers and will also reduce dependent edema and worsening lung function. Nutrition is important to help with healing and meeting the metabolic needs of the body, but not when a client is acutely ill and on a mechanical ventilator. Additionally, frequent chest x-rays expose the client to too much radiation.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client's safety? Select all that apply. a. padding bed rails b. airway at bedside c. bed in high position d. padded tongue blade e. flushing iv cath to make sure site is patent

a. padding bed rails b. airway at bedside d. padded tongue blade e. flushing iv cath to make sure site is patent Rationale:Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse would be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they would not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. a. pt is aphasic b. weakness on right side of the body c. complete bilateral paralysis of the arms/legs d. weakness on right side of the face/tongue e. lost ability to move right arm but is able to walk independently f. lost ability to ambulate independently but is able to feed and bathe self without assistance

a. pt is aphasic b. weakness on right side of the body d. weakness on right side of the face/tongue Rationale:Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is evaluating the use of a cane for a client who sustained a stroke who has residual left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performs which action? A. holds the can on the right side b. moves the cane when the right leg is moved c. leans on the cane when the right leg swings through d. keeps the cane 6 inches out to the side of the right foot

b. The cane is held on the stronger side to minimize stress on the affected extremity and to provide a wide base of support. The cane is held 4 to 6 inches (10 to 15 cm) lateral to the fifth toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the leg on the stronger side swings through.

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104° F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Acetaminophen (Tylenol) 650 mg rectally. b. Administer normal saline IV at 500 mL/hr. c. Start norepinephrine to keep blood pressure above 90 mm Hg. d. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

b. Administer normal saline IV at 500 mL/hr. Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository

b. Blood cultures from two sites Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

Which finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Flank tenderness to palpation b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1° F (57.8° C)

b. Blood pressure 90/48 mm Hg The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

The client is admitted to a renal medical unit. Which factors most likely increase the client's risk for developing urosepsis? Select all that apply. a. The client is a vegetarian b. The client has diabetes mellitus c. The client has renal disease and one functioning kidney d. The client is voiding 400 mL every 6 hours e. The client has recurring urinary tract infections (UTIs.)

b. The client has diabetes mellitus c. The client has renal disease and one functioning kidney e. The client has recurring urinary tract infections (UTIs.) Rationale, Strategy, Tip Rationale:UTIs can lead to urosepsis. Diabetics have an increased risk of developing UTIs and therefore urosepsis. If the blood glucose is uncontrolled, then there will be an increase of glucose present, leading to infection. A client who has only one functioning kidney has a risk because damage can be done to the kidney remaining if the client has any lingering chronic medical problems. Recurring UTIs can damage the kidneys, making them more prone to infections.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain. b. The patient with neutropenia who has a temperature of 101.8° F. c. The patient with thrombocytopenia who has oozing gums after a tooth extraction. d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours.

b. The patient with neutropenia who has a temperature of 101.8° F. A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system. c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

b. Use a fecal management system. Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

A client is brought to the emergency department with partial-thickness burns to the face, neck, arms, and chest after trying to put out a car fire. The nurse needs to implement which nursing actions for this client? Select all that apply. a. restrict fluids b. assess for airway patency c. administer prescribed o2 d. place cooling blanket on pt e. elevate extremities if no fractures present f. prepare to give oral pain meds

b. assess for airway patency c. administer prescribed o2 e. elevate extremities if no fractures present Rationale:The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

A new graduate nurse is taking a critical care course focusing on cardiogenic shock. Which statement made by the graduate nurse indicates that the teaching was effective? a. cardiogenic shock is caused by diuretics b. cardiac tissue death can lead to cardiogenic shock c. cardiac arrest is the most common cause for cardiogenic shock d. each valve within the heart must be faulty to decrease cardiac output

b. cardiac tissue death can lead to cardiogenic shock Rationale: Cardiogenic shock is the failure of the heart to pump adequately. This results in decreased cardiac output and decreased tissue perfusion. Cardiac tissue or vessel necrosis can lead to an occlusion within the heart vessels themselves, thus affecting the heart's ability to pump properly. It is not caused by diuretics. Options 3 and 4 are incorrect.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse would use which technique to test the client's peripheral response to pain? a. sternal rub b. pressure on nail beds c. pressure on orbital rim d. squeezing of sternocleidomastoid muscle

b. pressure on nail beds

A patient is admitted to the emergency department (ED) in shock of unknown etiology. What should be the nurse's first action? a. Obtain the blood pressure. b. Check the level of orientation. c. Administer supplemental oxygen. d. Obtain a 12-lead electrocardiogram.

c. Administer supplemental oxygen. The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be done as rapidly as possible after providing O2.

To evaluate the effectiveness of the pantoprazole (Protonix) given to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Check stools for occult blood. d. Palpate for abdominal tenderness.

c. Check stools for occult blood. Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Send a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for a (CT) scan.

c. Infuse a liter of lactated Ringer's solution over 30 minutes. The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

After a patient who has septic shock receives 2 L of normal saline intravenously, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate? a. Furosemide b. Nitroglycerin c. Norepinephrine d. Sodium nitroprusside

c. Norepinephrine When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.

c. Notify the health care provider. The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? a. Give the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol). c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.

c. Obtain oxygen saturation using pulse oximetry. The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/μL after chemotherapy. b. Patient who has xerostomia after receiving head and neck radiation. c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C.) d. Patient who is worried about getting the prescribed long-acting opioid on time.

c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C.) Fever is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/μL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain.

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases. b. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/min. c. Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. d. Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg.

c. Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not need immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually need treatment in patients with a spinal cord injury. The findings for the patient admitted with anaphylaxis show resolution of bronchospasm and hypotension.

After reviewing the information shown below for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? 1) Physical Assessment - Petechiae noted on chest and legs. - Crackles heard bilaterally in lung bases. - No redness or swelling at central line IV site. 2) Laboratory Data - BUN 34. - Hematocrit 30%. - Platelets 50,000. 3) Vitals - T 100F. - HR 102. - BP 110/60 - SpO2 93% via 2L nasal cannula. a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate

c. Platelet count and presence of petechiae The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will be discussed with the health care provider but does not show that the patient's condition is deteriorating or that a change in therapy is needed immediately.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. There are no signs of hemorrhage. b. Hemoglobin is within normal limits. c. Urine output 65 mL over the past hour. d. Mean arterial pressure (MAP) is 72 mm Hg.

c. Urine output 65 mL over the past hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? a. clear CSF, decreased pressure, and elevated protein level b. clear CSF, elevated protein, decreased glucose levels c. cloudy CSF, elevated protein, decreased glucose levels d. cloudy CSF, decreased protein, decreased glucose levels

c. cloudy CSF, elevated protein, decreased glucose levels Rationale:Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? a. negative kernig's sign b. absence of nuchal rigidity c. positive brudzinski's sign d. GCS 15

c. positive brudzinski's sign Rationale:Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

A client admitted with fever has now been diagnosed with urosepsis. What symptoms are the priority for the nurse to manage? a. hypertension, oliguria, prolonged capillary refill b. restlessness, decreased HR, pale skin c. progressive generalized edema, weak & thready pulse d. BP 140/85, increased urinary output

c. progressive generalized edema, weak & thready pulse Rationale:Urosepsis is a severe infection originating in the urinary tract. Sepsis, if not managed can progress into shock. Early identification and treatment are crucial to the client's response and survival. Hypotension rather than hypertension occurs, eliminating options 1 and 4. Option 2 lists symptoms that are important to monitor, but option 3 identifies the symptoms with the highest priority. Additionally, an increased rather than decreased heart rate is likely to occur if shock is developing.

The nurse is reviewing the record of a child with increased intracranial pressure from a head injury and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? a. paralysis of all extremities b. adduction of the arms at the shoulders c. rigid extension & pronation of the arms & legs d. abnormal flexion of the upper extremities & extension & adduction of the lower extremities

c. rigid extension & pronation of the arms & legs Rationale:Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. a. urine output 50 mL/hr b. hypoactive bowel sounds c. temp of 102 d. HR 96 e. MAP of 65 f. systolic BP of 110

c. temp of 102 d. HR 96 e. MAP of 65 Rationale:Sepsis diagnostic criteria with regard to signs and symptoms include the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia (core temperature lower than 97° F [36° C]), heart rate above 90 beats per minute, tachypnea (respiratory rate above 22 breaths per minute), systolic blood pressure (SBP) less than or equal to 100 mm Hg or arterial hypotension (SBP below 90 mm Hg), MAP of less than 70 mm Hg, or a decrease in SBP of more than 40 mm Hg, altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel sounds), and decreased capillary refill or mottling of skin.

The nurse is caring for a client with cardiogenic shock. After reviewing the medication administration record, the nurse determines a need for follow-up when noticing which entry in the record? a. digoxin 0.5mg/day b. morphine 2mg IV PRN chest pain c. verapamil 10mg IV; can repeat every 15 minutes d. dopamine IV 1mcg/kg/min to maintain systolic BP > 100

c. verapamil 10mg IV; can repeat every 15 minutes Rationale:Medication management for clients in cardiogenic shock needs to focus on increasing cardiac output. Vasopressors and positive inotropes are examples of medications that will achieve this outcome. Additionally, clients may be prescribed pain medication to treat secondary symptoms and medications that help maintain blood pressure.

The charge nurse understands that there is a need for further teaching when the nurse caring for a client with septic shock states which of the following? a. "Frequent assessments of mental status may be necessary." b. "It will be important to watch the trend of the client's lab values." c. "Blood transfusions may be needed to help with the client's coagulopathy." d. "Administering antibiotics is the best way to correct and treat septic shock."

d. "Administering antibiotics is the best way to correct and treat septic shock." Rationale:Antibiotics are an important piece of the treatment and management of shock, but the treatment and management encompass many different interventions and methods, not just administering antibiotics. Discovering what the underlying condition is will be crucial in treating the client properly, and restoration of tissue perfusion and circulating volume must be achieved first. Options 1, 2, and 3 are correct actions.

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient's heart rate is 110 beats/min. c. The patient's peripheral pulses are weak. d. The patient reports diffuse chest pressure.

d. The patient reports diffuse chest pressure. Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion and cause chest pain or pressure. Low urine output, weal pulses, and tachycardia are consistent with the patient's diagnosis. They and should be reported to the health care provider but do not require an immediate need for a change in therapy.

What primary characteristic of cardiogenic shock helps determine what nursing interventions are performed? a. blood pools in the heart, so care is focused on diuresing b. urinary output is low, so care is focused on increasing circulatory volume c. hypotension is severe, so care is focused on blood pressure monitoring d. cardiac output is compromised, so care is focused on restoring tissue perfusion

d. cardiac output is compromised, so care is focused on restoring tissue perfusion Rationale:Cardiogenic shock occurs when the heart fails to pump adequately, thus reducing cardiac output and compromising tissue perfusion. The goal of management and treatment for cardiogenic shock is to restore cardiac output and tissue perfusion; then treatment of the underlying cause can be managed. Options 1, 2, and 3 are not primary characteristics.

A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention would the nurse implement first? a. increase flow of O2 b. obtain ABG c. Insert catheter d. increase IV fluid rate

d. increase IV fluid rate Rationale:The MAP and CVP are both low for this client, indicating a shock state. Shock is the result of inadequate tissue perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. Although increasing the rate of O2 flow may be a necessary intervention, perfusion is the first priority. Obtaining arterial blood gas results and inserting an indwelling urinary catheter may be necessary interventions to monitor the client's response to prescribed therapy, but these are not the priority.

Which client would most likely be the highest risk for systemic inflammatory response syndrome (SIRS)? a. pt admitted for new onset seizures b. pt admitted for new onset DM c. pt with GI bleeding ulcer d. pt with cancer & central line just placed

d. pt with cancer & central line just placed Rationale: The client with cancer is at increased risk for infection. In addition, this client is admitted for the placement of a central line, an invasive procedure. This combination would place this client at highest risk for developing SIRS secondary to an infection.