Acute Care nursing final
83. The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states?
a) Tachycardia. Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.
49. A nurse is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?
b) "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.
38. A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what?
a) Hemodynamic instability. The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.
31. Which condition may contribute to hyperparathyroidism?
b) Chronic renal failure. Because failing kidneys can't convert vitamin D, the serum calcium level declines. Parathyroid hormone release increases, causing hyperparathyroidism. Thyroidectomy may lead to hypoparathyroidism if the parathyroid is also removed during surgery. Serum calcium level may rise as a result of hyperparathyroidism, so it isn't a contributing factor. Steroid use causes calcium to leave bone, suppressing parathyroid hormone.
79. The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
b) Cool, clammy skin. In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patient's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.
37. A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be aware of what main goal of care?
b) Cure of the disease. The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and symptom control are vital, but the overarching goal is the cure the disease.
67. A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care?
b) Fluid status. During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.
39. A male client has a hemoglobin count of 10.2 gm/dl, a hematocrit value of 36%, and a low ferritin level. What question should the nurse ask first?
b) Have you experienced abdominal pain? The laboratory data support that the client has iron-deficiency anemia. The most common cause of iron-deficiency anemia in men is bleeding from ulcers, gastritis, inflammatory bowel disease, or gastrointestinal tumors. People who experience these problems may report abdominal pain. The nurse will make further assessments and may ask the other questions.
62. The nurse's assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention?
b) IV calcium gluconate. When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.
26. You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
b) Neurologic examination. A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.
13. An 80-year-old male client who has been informed by his physician that he has arteriosclerosis is confused by what this means. The nurse explains that arteriosclerosis is a:
c) Expected part of the aging process. Arteriosclerosis is loss of elasticity or hardening of the arteries that accompanies the aging process. While arteriosclerosis is a contributing factor to vascular occlusive disease, it is a term that refers to a loss of elasticity or hardening of the arteries that accompanies the aging process. Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Hyperlipidemia, or high levels of blood fat, triggers atherosclerotic changes.
100. A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
c) Face the client and establish eye contact. When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal.
32. Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?
c) Head injury . An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.
56. A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?
d) Throbbing headache or dizziness. Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.
29. Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit?
d) To prevent contractures and joint deformities. The long-term outcome for rehabilitation is directed toward maintaining musculoskeletal functioning. The risk for ineffective cerebral tissue perfusion is of most concern during the acute phase rather than rehab phase of care. Developing appropriate coping mechanisms in dealing with loss of body function or image is important but not as significant as musculoskeletal integrity. Activity tolerance should increase during rehab but not a primary concern.
88. A client with a history of allergies comes to the emergency department. The nurse suspects anaphylaxis based on what sx?
Chest tightness, generalized itching, pallor, massive facial angioedema, tachycardia or bradycardia, and decreasing blood pressure (as a result of peripheral vascular collapse).
16. When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
c) Irritability and drowsiness. Although all the options are associated with hepatitis B, the onset of irritability and drowsiness suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness and should monitor the results of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions.
93. The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply.
c) Menstruation f) Red wine. Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation) and particular food/beverages can be a trigger for some clients. Nausea is a symptom of a migraine. Exposure to bright light and changes in environmental temperature are not triggers for migraine headaches. Prolonged positioning can cause muscle fatigue and strain that trigger tension headaches.
57. The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified?
c) Obesity, inactivity, diet, and smoking. The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.
18. A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
d) Check the patient's indwelling urinary catheter for kinks to ensure patency.. A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the patient's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.
64. A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend?
d) Consumption of a high-protein diet. Muscle wasting can be partly addressed through increased protein intake. Passive ROM exercises maintain flexibility, but do not build muscle mass. Vitamin D and calcium supplements do not decrease muscle wasting. Activity limitation would exacerbate the problem.
19. The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
d) Pulse and blood pressure. Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
87. The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?
d) Septic. In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.
43. The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?
d) Sympathetic nervous system. The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous system regulates "feed and breed" functions. The central and peripheral nervous system is a component of the sympathetic nervous system.
15. The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. Why?
d) Trauma and micro abrasions may contribute to anemia. In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.
85. A nurse knows that the major clinical use of dobutamine (Dobutrex) is to:
d) increase cardiac output. Dobutamine increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
1. When vasoactive medications are administered, the nurse must monitor vital signs at least how often?
15 min When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).
9. The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what?
A lower motor neuron lesion. Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It is not a genetic disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.
8. Which type of shock occurs from an antigen-antibody response?
Anaphylactic. During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.
6. The nurse is caring for a patient diagnosed with unstable angina receiving IV heparin. The patient is placed on bleeding precautions. Bleeding precautions include which of the following measures?
Avoiding continuous BP monitoring.The patient receiving heparin is placed on bleeding precautions, which can include: applying pressure to the site of any needle punctures for a longer time than usual, avoiding intramuscular injections, avoiding tissue injury and bruising from trauma or constrictive devices (e.g. continuous use of an automatic BP cuff). SQ injections are permitted; a soft toothbrush should be used, and the patient may use nail clippers, but with caution.
10. A patient was admitted to the hospital with the following lab values: hemoglobin 5 g/dL, abnormally shaped erythrocytes, leukocyte count 2000/mm3 with hypersegmented neutrophils and a platelet count of 48,000/mm3. The platelets appear abnormally large. A bone marrow biopsy was competed and revealed hyperplasia. Based on this information, the nurse determines that patient most likely has which of the following diagnoses?
Folic acid deficiency. Anemia caused by a deficiency of folic acid cause bone marrow and peripheral blood changes. The erythrocytes that are produced are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid stem cell are also abnormal. A bone marrow analysis reveals hyperplasia (abnormal increase in the number of cells). Pancytopenia (a decrease in all myeloid stem cell-derived cells) can develop. In advanced stages of disease, the hemoglobin value may be as low as 4 to 5 g/dL, the leukocyte count 2,000 to 3,000/mm3, and the platelet count less than 50,000/mm3. Cells that are released into the circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be abnormally large. The erythrocytes are abnormally shaped.
4. A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate?
IV administration of octreotide (Sandostatin). Octreotide (Sandostatin)—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.
5. The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
Multiple organ failure. In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a "point of no return" despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
7. An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB, keep the head in neutral alignment with no neck flexion or head rotation, avoid sharp hip flexion?
To avoid impeding venous outflow. Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.
46. A nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching?
a) "This disease doesn't cause sensory impairment." Myasthenia gravis affects motor function; therefore, the nurse should inform the client that sensory impairments won't occur. This disease is chronic; there's no cure. It can be managed with edrophonium in the diagnostic phase; however, this drug isn't used to treat the condition.
77. A patient is admitted to the emergency department (ED) following a motorcycle accident. Upon assessment, the patient's vital signs reveal blood pressure (BP) of 80/60 mm Hg and heart rate (HR) of 145 beats per minute (bpm). The patient's skin is cool and clammy. Which of the following patient medical orders will the nurse complete first?
a) 100% oxygen per nonrebreather mask. The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address the metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied per a nonrebreather mask. The other orders should be completed after the patient's airway is secured.
44. A patient presents to the emergency room complaining of chest pain. The patient's orders include the following elements. Which order should the nurse complete first?
a) 12-lead ECG. The nurse should complete the 12-lead ECG first. The priority is to determine if the patient is suffering an acute MI and implement appropriate interventions as quickly as possible. The other orders should be completed after the ECG.
55. A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient?
a) Bleeding at insertion site. Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and none is emergent.
74. The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic shock?
a) Bradycardia. In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.
53. A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause?
a) Coronary arteriosclerosis. In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.
89. A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient?
a) DVT b) Autonomic dysreflexia c) Orthostatic hypotension. For a spinal cord-injured patient, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not typical complications following the immediate recovery period.
90. Which of the following provides clues about fluid volume status? Select all that apply.
a) Daily weights e) Hourly urine output . Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.
25. The acute care nurse is providing care for an adult patient who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock?
a) Decreased urinary output. During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.
17. Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns?
a) Deep tissue cooling. Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.
94. A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply.
a) Fatigue from anemia d) Frequent infections e) Easy bruising. Infections, fatigue from anemia, and easy bruising are hallmarks of leukemia. At the onset of leukemia, particularly in acute lymphocytic leukemia (ALL), a fever is present, the spleen and lymph nodes enlarge, and internal or external bleeding develops. Diarrhea and nausea and vomiting are not the hallmark signs of leukemia and can be indicators in many illnesses and gastrointestinal disorders.
86. In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances?
a) Fluid volume circulating in the blood vessels decreases. Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.
54. An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?
a) Greater saphenous vein. The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
60. A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal?
a) Hypocalcemia. Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the physician immediately, because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia.
99. Which nursing diagnosis is the most appropriate for a client with a strained ankle?
a) Impaired physical mobility. Ankle strains result in pain and damage to the ligaments as well as Impaired physical mobility. Although the traumatic event that caused the strain may disrupt the skin, the manifestations of a strain don't warrant a nursing diagnosis of Impaired skin integrity. Risk for deficient fluid volume is an appropriate nursing diagnosis for a process that results in the loss of a large volume of fluid or blood; it isn't appropriate for a client with a strained ankle. Disturbed body image would be appropriate if the client's livelihood alters because of the strain.
11. The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?
a) Increase the force of myocardial contraction. The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.
28. The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock?
a) Lactated Ringer's. Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer's and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.
91. A patient with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the patient should be informed that this procedure will involve the removal of which of the following?.
a) Part of the stomach b) Gallbladder d) Part of the common bile duct e) Duodenum. A pancreaticoduodenectomy (Whipple procedure or resection) is used for potentially resectable cancer of the head of the pancreas (Fig. 50-7). This procedure involves removal of the gallbladder, a portion of the stomach, duodenum, proximal jejunum, head of the pancreas, and distal common bile duct. The rectum is not affected.
84. An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock?
a) Remove invasive devices as soon as they are no longer needed. Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.
52. The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?
a) T wave inversion. T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.
76. The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patient's nutritional needs. What physiologic process contributes to these increased nutritional needs?
a) The release of catecholamines that creates an increase in metabolic rate and caloric requirements. Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.
45. A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What patient education is most accurate?
b) "Most people feel some brief, sharp pain when the needle enters the bone." Patients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, but brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the patient should be warned about this. Stating, "I'll try to help you keep your mind off the pain" may increase the patient's fears of pain, because this does not help the patient know what to expect.
33. Which of the following is one of the most common causes of death in patients diagnosed with fat emboli syndrome?
b) ARDS. Acute pulmonary edema and ARDS are the most common causes of death.
36. A patient is brought to the ED by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse will complete which of the following interventions first?
b) Apply a cervical collar on the patient.. Until it is known that the patient has no fractures, it is imperative that a neck collar be applied and remain in place and that the patient is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.
51. The nurse is teaching a patient who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the patient chooses which of the following food choices from the menu?
b) Pancakes with butter and honey and orange juice. Teach patients to select a diet high in carbohydrates with protein intake consistent with liver function. The patient should identify foods high in carbohydrates and within protein requirements (moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure). The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia levels. The other choices are all higher in protein. The patient's ascites indicates that a low-sodium diet is needed and the other choices are all high in sodium.
59. A patient's blood work reveals a platelet level of 17,000/mm3. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level?
b) Petechiae. When the platelet count drops to less than 20,000/mm3, petechiae can appear. Low platelet levels do not normally result in dermatitis, urticaria (hives), or alopecia (hair loss).
40. The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client?
b) Pneumococcal vaccine. Without a spleen, the client's risk of infection is greatly increased. The pneumococcal vaccine should be administered, preferable before splenectomy. Aspirin should not be administered due to the increased risk of bleeding. IgG is administered to client with increased chance of bacterial infections but is not routinely given to client undergoing splenectomy, as is the pneumococcal vaccine. Factor VII is given to treat bleeding disorders.
78. Morphine sulfate has which of the following effects on the body?
b) Reduces preload . In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).
58. A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following?
b) Reducing the heart's workload by decreasing heart rate and myocardial contraction. Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.
68. The nurse is preparing the patient for mechanical débridement and informs the patient that this will involve which of the following procedures?
b) Removal of eschar until the point of pain and bleeding occurs. Mechanical débridementcan be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement.
14. A patient complains of pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The patient was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury?
b) Sprain. A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.
35. A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered?
b) Tacrolimus (Prograf, FK506). In preparation for a liver transplant, a client receives immunosuppressants to reduce the risk for organ rejection. Tacrolimus and cyclosporine are two immunosuppressants that may be used. Chenodiol and ursodiol are agents used to dissolve gallstones. Recombinant interferon alfa-2b is used to treat chronic hepatitis B, C, and D to force the virus into remission.
81. The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following?
b) The difference between the systolic and diastolic pressure. The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
41. A client with hypertension comes to the outpatient department for a routine checkup. Because hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client?
b) Tinnitus. Tinnitus is commonly a warning sign of cerebral hemorrhage. Other warning signs include vomiting (without nausea), a change in level of consciousness, and localized seizures. Vertigo isn't a common indicator of cerebral hemorrhage.
69. A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
b) Urine output of 20 ml/hour. A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.
96. An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn?
b) Wrap cool towels around the affected extremity intermittently. Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Butter is contraindicated.
70. A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
b) maintaining the client's fluid, electrolyte, and acid-base balance. After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Planning for the client's rehabilitation and discharge, providing emotional support, and preserving full range of motion in all affected joints are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.
27. The nurse has completed a teaching session on the self-administration of sublingual nitroglycerin. Which of the following patient statements indicates that the patient teaching has been effective?
c) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". Nitroglycerin can be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e. before angina-producing activity, such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops. The client is instructed to take three tablets 5 minutes apart and if the chest pain is not relieved emergency medical services should be contacted. Nitroglycerin is very unstable; it should be carried securely in its original container (e.g., capped dark glass bottle); tablets should never be removed and stored in metal or plastic pillboxes. Side effects of nitroglycerin includes: flushing, throbbing headache, hypotension, and tachycardia.
63. What should the nurse teach a patient on corticosteroid therapy in order to reduce the patient's risk of adrenal insufficiency?
c) Always have enough medication on hand to avoid running out. The patient and family should be informed that acute adrenal insufficiency and underlying symptoms will recur if corticosteroid therapy is stopped abruptly without medical supervision. The patient should be instructed to have an adequate supply of the corticosteroid medication always available to avoid running out. Doses should not be skipped or added without explicit instructions to do so. Corticosteroids should normally be taken in the morning to mimic natural rhythms.
22. A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which of the following individuals is most likely to have anemia?
c) An 81-year-old woman who has chronic heart failure. The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of anemia is compounded by the presence of heart disease. None of the other listed individuals exhibits high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia.
24. A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?
c) Blurred vision, intention tremor, and urinary hesitancy. Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski's reflex is found in MS. Abdominal reflexes are absent with MS.
47. The nurse is providing education to a group of young people about the dangers of tattoos and body piercings. Which of the following would the nurse describe as a possible result of a tongue piercing?
c) Brain abscess. A brain abscess can result from intracranial surery, penetrating head injury, or tongue piercing. The other choices are not associated with tongue piercing.
61. The nurse is assessing a patient diagnosed with Graves' disease. What physical characteristics of Graves' disease would the nurse expect to find?
c) Bulging eyes. Clinical manifestations of the endocrine disorder Graves' disease include exophthalmos (bulging eyes) and fine tremor in the hands. Graves' disease is not associated with hair loss, a moon face, or fatigue.
92. Which of the following are early manifestations of liver cancer? Select all that apply.
c) Continuous aching in the back, and pain. Early manifestations of liver cancer include pain and continuous dull aching in the right upper quadrant epigastrium or back. Weight loss, anorexia, and anemia may occur. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever and vomiting are not associated manifestations.
73. When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect?
c) Decreased venous return. Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.
21. When the ED nurse learns that a patient suffered a burn injury from a flash flame, the nurse anticipates which depth of burn?
c) Deep partial thickness. A deep partial thickness burn, which is similar to a second-degree burn, is associated with scalds and flash flames. Superficial partial thickness burns, similar to first-degree burns are associated with sunburns. Full thickness burns, similar to third-degree burns, are associated with direct flame, electricity, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.
80. The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?
c) Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Informing the patient's family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues.
48. Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following?
c) Tachycardia . Cranial nerve demyelination can result in a variety of clinical manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system. The presentation is variable and may include tachycardia, bradycardia, hypertension, or orthostatic hypotension.
42. The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?
c) The client with a basilar fracture. Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.
66. An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
c) The total body surface area (TBSA) affected by the burn. Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.
75. How should vasoactive medications be administered?
c) Using a central venous line . Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push.
34. Lillian Anderson, a 73-year-old retired dancer, is being seen by a neurologist in the group where you practice nursing. She reports light-headedness, speech disturbance, and left-sided weakness, which lasted for several hours. The neurologist diagnosed a transient ischemic attack, which caused Ms. Anderson great concern. During your client education with Ms. Anderson, you would include which of the following?
c) When symptoms cease, she will return to her pre symptomatic state.. Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.
97. A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?
d) "Exercise, keep your cholesterol in check, and manage your stress." Although moderation is the key, this does not provide specific options for this client such as regular exercise and managing stress and cholesterol levels. The reverse lipid drug sounds good but is not available or approved by the FDA. Soy products have limited benefits for cholesterol control.
95. A patient's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply.
d) "How many alcoholic drinks do you typically consume in a week?" and e) "Have you ever been diagnosed with gallstones?" . Eighty percent of patients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes, high-fat consumption, and cystic fibrosis are not noted etiologic factors.
98. A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?
d) "Rehabilitation will help me function as well as I physically can." The client demonstrates understanding of cardiac rehabilitation when he states that it helps the client reach his activity potential. Coronary artery disease, which typically causes an acute MI, is a chronic condition that isn't cured. Many clients who suffer an acute MI can eventually return to such activities as jogging, depending on the extent of cardiac damage. Cardiac rehabilitation involves physical activity as well as classroom education.
12. A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care?
d) Assessment for variceal bleeding. Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.
72. A 34-year-old female client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client?
d) Control the shivering. Hyperthermia may develop related to altered temperature regulation secondary to sepsis. Because the act of shivering increases body heat through the contraction of skeletal and pilomotor muscles in the skin, it is important to get the shivering under control. This would not be an appropriate intervention because this client is septic and hyper thermic. Conduction and radiation transfer heat, which would increase the client's body temperature. Hyperthermia may develop related to altered temperature regulation secondary to sepsis. This intervention would not help this client because measures that prevent evaporation and heat loss from radiation interfere with the loss of body heat. This intervention is appropriate for clients with ineffective peripheral tissue perfusion.
50. Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion?
d) Contusion. Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brain stem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.
20. A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and his family to expect which common symptom that typically resolves spontaneously?
d) Depression. For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves without medical intervention. However, the nurse should advise family members that symptoms of depression don't always resolve on their own. They should make sure they recognize worsening symptoms of depression and know when to seek care. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure. Because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition following CABG surgery. This symptom warrants immediate physician notification.
82. The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications?
d) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration. When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patient's response. Reviewing medications, performing a focused cardiovascular assessment, and providing patient education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema are not the priorities for administration of IV vasoactive drugs. Vital signs are taken on a frequent basis when monitoring administration of IV vasoactive drugs, vasoactive medications should be administered through a central venous line, and early discharge instructions would be inappropriate in this time of crisis.
65. A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?
d) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis. Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.
23. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
d) Hyperthermia. Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.
30. A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding?
d) Octreotide (Sandostatin). Acute hemorrhage from esophageal varices is life threatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide (Sandostatin) is started as soon as possible. Sandostatin is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin (Pitressin) or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.
71. Which instruction is the most important to give a client who has recently had a skin graft?
d) Protect the graft from direct sunlight. To prevent burning and sloughing, the nurse must instruct the client to protect the graft from direct sunlight. Continuing physical therapy, using cosmetic camouflage techniques, and applying lotion to the graft site are appropriate instructions, but they aren't the most important concern in the client's recovery.
2. A patient arrives at the ED via ambulance following a motor cycle accident. The paramedics state the patient was found unconscious at the scene of the accident, but briefly regained consciousness during transport to the hospital. Upon initial assessment, the patient's GCS score is 7. The nurse anticipates which of the following?
immediate craniotomy. The patient is experiencing an epidural hematoma. An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease ICP emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. During this lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume, both of which help to maintain the ICP within normal limits. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma.
3. Cardiogenic shock is most commonly seen in which patient population?
myocardial infarction Cardiogenic shock is seen most often in patient with myocardial infarction.
