Adult II Final & ATI MedSurg CME (2-for-1 value pack)
What does a positive Kernig sign, Brudzinski sign, photophobia, and nuchal rigidity mean? 1.Infection 2.Increased intracranial pressure 3.Meningeal irritation 4.Cranial nerve dysfunction
3.Meningeal irritation
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following actions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms. B. The client internally flexes his wrists. C. The client curls into a fetal position. D The client internally rotates his legs.
A. The client rigidly extends his arms. decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline. Incorrect Answers: B. A client who exhibits decorticate posturing internally flexes the wrists and arms and extends and plantar-flexes the legs. C. A fetal position is not a manifestation of a decerebrate posture. D. A client who exhibits decorticate posturing flexes the arms with internal rotation of the forearms and extends and plantar-flexes the legs.
A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? Occipital Temporal Frontal Limbic
Frontal Posterior portion of the frontal lobe is responsible for the verbal expression of thoughts Incorrect Answers: A. The occipital lobe is responsible for vision. B. The temporal lobe is responsible for understanding speech. D. The limbic lobe is responsible for memory and learning.
In cases of TBI, the cerebral vasculature has the risk for developing?
intracranial bleed which may involve more than one vessel.
A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following venous fluids is contraindicated for this client? A. Whole blood B. Lactated Ringer's C. Dextran 40 in 0.9% sodium chloride D. 0.45% sodium chloride
0.45% sodium chloride is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L, which is less than the expected reference range of the osmolarity value for plasma and body fluid of 285 to 295 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid. Incorrect Answers: A. The nurse should plan to administer whole blood to the client if the client's hematocrit is <20% to 25%, which can result from hemodilution caused by fluid replacement therapy B. Plan to administer LR which is an isotonic solution used to expand vascular volume. C. Plan to administer dextran 40 in 0.9% sodium chloride, which is an isotonic colloid solution, to increase the intravascular fluid volume.
A nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? A. A client who is difficult to arouse and is unable to respond to questions B. A client who has slurred speech and exhibits anger C. A client who reports nausea and vomiting D. A client who is uncooperative and has uncoordinated movements
A client who is difficult to arouse and is unable to respond to questions The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identity which risk poses the greatest threat to the client. A client who is difficult to arouse and is unable to respond to questions could have a decreased level of consciousness due to an alcohol intoxication level of 401-800 mg/dL or traumatic brain injury. The greatest risk to this client is the neurological sequelae of head trauma or death due to severe alcohol intoxication. Incorrect Answers: B. Speech impairment and mood changes are common findings in alcohol intoxication. The nurse should intervene for this client but assess another client first. C. Nausea and vomiting are common findings in alcohol intoxication. The nurse should intervene for this client but assess another client first. D. Reduced coordination and mood and behavioral changes are common with alcohol intoxication. The nurse should intervene for this client but should assess another client first.
A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (CN VIII)? A. Dizziness and hearing loss B. Weakness of a side of the tongue C. Facial droop and asymmetrical smile D. Loss of the same visual field in both eyes
A. Dizziness and hearing loss Dizziness and hearing loss reflect alterations in the vestibulocochlear area, which CN VIl innervates. Incorrect Answers: B. Weakness of the tongue indicates damage to CN XII. C. Facial droop and an asymmetrical smile indicate damage to CN VII. D. Loss of the same visual field in both eyes (hemianopsia) indicates damage to the optic tract, which connects to CN II.
A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during a visit but does not respond verbally to Questions. The nurse should document this as which of the following alterations? • A. Expressive aphasia • B. Dysarthria • C. Receptive aphasia • D. Dysphagia
A. Expressive aphasia A client who has expressive aphasia understands speech but has difficulty speaking and writing. This typically occurs as a result of Broca's area of the frontal lobe. Incorrect Answers: B. A client who has dysarthria has slurred speech. C. A client who has visual receptive aphasia has difficulty understanding written words. D. A client who has dysphagia has difficulty swallowing because d is for dumbazz who cant breathe
A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia
A. Hyperkalemia The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid. Incorrect Answers: burn injuries. B. A low sodium level is not a manifestation of respiratory acidosis. Causes of hyponatremia include diuretics, kidney disease, vomiting, and C. A high calcium level is not a manifestation of respiratory acidosis. Causes of hypercalcemia include kidney failure and hyperparathyroidism. D. A low magnesium level is not a manifestation of respiratory acidosis. Causes of hypomagnesemia include malnutrition, alcohol use disorder, and diarrhea.
A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises в. Use clean technique to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest
A. Initiate range-of-motion exercises THINK -> Contractures The nurse should begin performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures. Incorrect Answers: B. The nurse should use sterile technique to provide wound care for this client to reduce the risk of infection. C. The nurse should place the client on a high-protein, high-calorie diet to promote wound healing. D. The nurse should encourage the client to ambulate frequently to promote mobility and improve ventilation.
A nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). Which of the following instructions should the nurse include? A. Reduce dietary sodium B. Decrease dietary potassium C. Restrict intake of insoluble fiber D. Limit alcohol intake to ≤3 servings per day
A. Reduce dietary sodium A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs. Incorrect Answers: B. Dietary management of hypertension, which is a major cause of TIAs, includes an increased intake of dietary potassium. C. Dietary management of hypertension includes increased fiber. D. Dietary management of hypertension includes limiting alcohol intake to no more than 2 servings for men or 1 serving for women per day.
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the tollowing findings indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L B. The client's pupils are dilated. C. The client's heart rate is 56/min. D. The client is restless.
A. The client's serum osmolarity is 310 mOsm/L Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP. Incorrect Answers B. Dilated pupils, pinpoint pupils, and asymmetrical pupils are manifestations of increased ICP. C. Bradycardia is a manifestation of increased ICP. D. Restlessness and behavioral changes are manifestations of increased ICP.
A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home? • A. Blood glucose • B. Blood pressure • C. Daily weight • D. Sensation in the feet
B. BP A temporary disturbance of the blood supply to the brain causes a TIA, which is a brief alteration in neurological function. The most c causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to prom hypertension management and reduce the risk of another TIA or cerebrovascular accident. Incorrect Answers: A. This is a recommendation for clients who have diabetes mellitus. C. This is a recommendation for clients who have impairments of fluid balance. D. This is a recommendation for clients who have actual or potential circulatory impairments from disorders that affect the lower extremities, such as ischemic ulcers, fractures, and diabetes mellitus.
A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury •B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output
B. Characteristics of the cough and sputum The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse's priority assessment is the client's cough characteristics. A client who has burns to the face is at risk for pulmonary injury, and the development of a brassy cough can indicate an impending loss of airway. Incorrect Answers: A. The nurse should determine the percentage of the client's total body surface area that is burned to ensure proper care and provide an estimation of prognosis; however, there is another assessment that the nurse should perform first. C. The nurse should assess the extent of the client's edema to determine the effects of the injury on the client's cardiovascular status; however, there is another assessment that the nurse should perform first. D. The nurse should accurately monitor the client's urine output to assess kidney function; however, there is another assessment that the nurse should perform first.
A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp
B. Clear fluid coming from the nares CSF manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture. Incorrect Answers: A. Although a client who has a depressed fracture of the forehead might also have additional head trauma, this finding does not indicate a basilar skull fracture, which occurs at the base of the skull. C. Motor loss on one side of the body is an indication of an injury to the cerebral hemisphere. The motor dysfunction will be contralateral to the site of, which mean on the opposite side of, the injury, similar to the results of a stroke. Loss of motor function can also be an indication that injury has occurred to the spinal cord. D. Although a client who has bleeding from the scalp might also have additional head trauma, this finding does not indicate a basilar skull fracture.
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains at it is obtained from which of the following sources? A. Cadaver skin B. Pig skin C. Amniotic membranes D. Beef collagen
B. Pig skin Heterografts are obtained from an animal, usually a pig. Incorrect Answers: A. Homographs are obtained from cadaver skin. C. Human amniotic membranes are used to treat burns; however, they are not heterograft dressings. D. Artificial skin made from beef collagen is used to treat burns; however, it is not a heterograft dressing.
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the blowing actions should the nurse perform next? A. Administer nifedipine B. Place the client in a high-Fowler's position C. Check for urinary retention D. Check for a fecal impaction
B. Place the client in a high-Fowler's position According to evidence-based practice, the nurse should first place the client in a high-Fowler's position to decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure. Incorrect Answers: A. plan to administer nifedipine to treat sudden severe hypertension, which can be life-threatening and requires immediate administration of an antihypertensive medication. However, evidence-based practice indicates that the nurse should take a different action first. C. The nurse should check for urinary retention since this can be the stimulus that discharges the sympathetic reflex. The sympathetic reflex can cause manifestations of sudden hypertension, a throbbing headache, nasal congestion, flushing, sweating, and apprehension. However, evidence-based practice indicates that the nurse should take a different action first. D. The nurse should check for a fecal impaction since this can be the stimulus that discharges the sympathetic reflex. (not priority)
Nurse is caring for a client who has a brain-stem injury. Which of the following physiological functions should the nurse monitor? A. Understanding speech B. Respiratory effort C. Decision-making ability D. Temperature control
B. Respiratory effort The medulla in the brainstem controls the respiratory center. Incorrect Answers: A. The nurse should monitor understanding of speech for a client who has an injury to the temporal lobe of the brain. C. The nurse should monitor decision making and situational reactions of a client who has an injury to the frontal lobe of the brain. D. The nurse should monitor the temperature control of a client who has an injury to the hypothalamus.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL
B. Sodium 132 mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space. Incorrect Answers: A. anticipate an elevated hemoglobin level during the resuscitation phase due to the loss of fluid volume. C anticipate a low albumin level during the resuscitation phase. D. anticipate an elevated potassium level during the resuscitation phase.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN
B. Transient leukopenia is an ADR of silver sulfadiazine. Incorrect Answers: A. Silver sulfadiazine does not cause an electrolyte imbalance. C. Hyperchloremia and other electrolyte imbalances can be adverse effects of mafenide acetate solution or cream. D. Impaired kidney function is an adverse effect of gentamicin.
A nurse is walking along the unit when she sees smoke coming from the central supply room. After activating the fire alarm, which of the following actions should the nurse take? A. Place unused equipment between the fire doors. B. Turn off sources of oxygen near the fire. C. Place rolled blankets at the base of the fire. D. Keep the doors to the unit and client rooms open.
B. Turn off sources of oxygen near the fire while smoking a cig. Oxygen fuels fire, so the nurse should turn off all sources of oxygen near the fire.
A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60° B. Place the head of the bed flat with pillows under the client's neck and feet C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees
C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position
A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Het D. Decreased Hgb
C. Elevated Hct The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration. Incorrect Answers: A. expect the client to have hyperkalemia as a result of potassium being leaked from cellular injury. B. expect the client to have hyponatremia once sodium leaks into the interstitial space, causing decreased levels in the blood. D. Expect an increased hemoglobin level as blood volume is reduced by vascular dehydration.
An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions
C. Provide supplemental oxygen The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death. Incorrect Answers: A. The nurse should insert an indwelling urinary catheter to monitor the client's urinary output and fluid balance; however, there is another action the nurse should take first. B. The nurse should administer an osmotic diuretic if prescribed to decrease cerebral edema; however, there is another action the nurse should take first. D. The nurse should initiate seizure precautions to protect the client from injury; however, there is another action the nurse should take first.
A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased ICP. This increase in ICP is due to which of the following? A. Decreased cerebral perfusion B. Leakage of cerebral spinal fluid C. Rigid skull containing cranial contents D. Brain herniated into the brainstem
C. Rigid skull containing cranial contents The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP. Incorrect Answers: A. A decrease in cerebral perfusion is a result of increasing ICP, not the cause. This leads to brain tissue ischemia and edera, which can cause death if untreated. B. The leakage of cerebral spinal fluid occurs with a basilar skull fracture, which open traumatic injury rather than a closed traumatic injury. D. Brain herniation can occur as a result of untreated increased intracranial pressure and can lead to death. It is not a cause of increased intracranial pressure.
A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention A. Partial-thickness burn B. Stage Ill pressure ulcer C. Surgical incision D. Dehisced sternal wound
C. Surgical incision primary intention: clean wound is closed mechanically, Incorrect Answers: A.Partial-thickness burn: heals by spontaneous re-epithelialization. - involves the uppermost layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn. B. A stage Ill pressure ulcer will heal by secondary intention. D. A dehisced sternal wound can either close by secondary or tertiary intention.
A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters."
Correct Answer: A. "I will be on a special shower table." The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature; there is also a lower risk of wound infection. Incorrect Answers: B. The nurse should use warm water during the hydrotherapy treatment to help the client maintain adequate body temperature. C. The nurse should use soft washclots or gauze to scrub and debride the wounds gently. D. The nurse should leave small blisters intact but open large blisters.
A nurse is caring for a client who has an impairment of cranial nerve Il. Which of the following actions should the nurse perform to promote the client's safety? A. Initiate seizure precautions. B. Ensure the client receives a soft diet. C. Provide an obstacle-free path for ambulation. D. Instruct the client to use lukewarm water when showering.
Correct Answer: C. Provide an obstacle-free path for ambulation. Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve Il is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation. Incorrect Answers: A. Seizures are the result of various neurological and metabolic imbalances, such as hypocalcemia and hypomagnesemia; however, none of the cranial nerves affects seizure activity. B. Clients who have an impairment of cranial nerve IX require this precaution because they are likely to have difficulty swallowing. D. Clients who cannot accurately sense temperature extremes (e.g. those with peripheral neuropathy) should avoid hot-water showers. Cranial nerve Il does not affect the client's ability to sense temperature extremes.
A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed dilated pupils? A. Red tag B. Yellow tag C. Green tag D. Black tag
Correct Answer: D. Black tag The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible. Incorrect Answers: A. The nurse should assign a red tag, or a class I label, to clients who have life-threatening injuries but a high possibility of survival once they are stabilized. B. yellow tag/ Class Il label, to clients who have major injuries that are not ye life threatening. C. green tag, or a class III label, to clients who have minor injuries that are not life-threatening and do not need immediate attention
A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine
Correct Answer: D. Immobilize the client's cervical spine The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. A. The nurse should question the client's coworkers about the mechanism of injury, which can yield information that will aid the treatment of the client's injury. However, another action is the nurse's priority. B. The nurse should check the client's pupils for equality and reaction to light to help determine if the client has increased intracranial pressure from a cerebral hemorrhage. However, another action is the nurse's priority. C. The nurse should measure alertness using the Glasgow Coma Scale to determine the client's level of consciousness. However, another action is the nurse's priority.
A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. ATIA can be the result of cerebral bleeding C.A TIA can cause cerebral edema. D.A TIA can precede an ischemic stroke.
D. A TIA can precede an ischemic stroke. TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include the loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness. I ncorrect Answers: A. TIAs are brief episodes of a neurological deficit that last less than 24 hours after onset without any permanent disabilities. B. TIAs are caused by a temporary reduction of oxygen supply to the brain, such as from a thromboembolism or cerebral vasospasm. A hemorrhagic stroke can be the result of cerebral bleeding. C. Cerebral edema can be the result of a stroke. TlAs do not produce edema of the cerebrum.
A nurse is caring for a client who is recovering at home after inpatient treatment for burn injuries. To increase the protein density of the client's meals, which of the following recommendations should the nurse make to the client's caregiver? A. Use sour cream instead of plain yogurt B. Add honey to cooked cereals C. Use salad dressing in place of mayonnaise D. Add chopped hard-boiled eggs to soups and casseroles
D. Add chopped hard-boiled eggs to soups and casseroles Eggs are a good source of protein. Adding them to combination foods and coating meats with raw eggs before breading and cooking increases the protein density of those foods. Incorrect Answers: A. To increase protein density, the caregiver should use plain yogurt in place of sour cream. B. Adding honey to cereal increases the caloric density, not the protein density. C. Mayonnaise contains more protein than most salad dressings.
A nurse is assessing client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache
D. Report of a headache Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by -full bladder -distended rectum. Manifestations severe, throbbing headache; flushing of the face and neck; bradycardia; extreme hypertension. Incorrect Answers: A. Manifestations of autonomic dysreflexia include flushing above the level of injury and pallor below the level of injury. B. Manifestations of autonomic dysreflexia include hypertension rather than hypotension. C. Manifestations of autonomic dysreflexia include bradycardia rather than tachycardia.
A nurse is planning care for a client. Which of the following interventions should the nurse include in the plan? A. Advance diet to soft B. Perform active and passive range-of-motion (ROM) exercises twice daily C. Apply compression garments 23 hr daily D. Restrict visitors History and Physical A 32 year-old male experienced deep partial-thickness and full-thickness chemical burns to anterior torso and arms 36 hr ago. Burn: total body surface area - 20% NG to low intermittent suction 02 © 4 L via nasal cannula Surgical excision of wounds planned for post-burn day 3. Diagnostic Results Hgb 14 g/dL Hct 42% WBC 3,500/mm Platelets 120,000/mm pH 7.35 PaO 80 mmHg PaCO, 45 mmHg HCO, 23 mEc/L Nurses' Notes Client is occasionally confused to place and time. Bowel sounds hypoactive in all quadrants. Purulent exudate noted from burn wound on right arm. Wound has a strong odor.
D. Restrict visitors This client's WBC level is less than the expected reference range of 5,000 to 10,000/mm^3. The client is at increased risk for infection from others, so the nurse should restrict visitors to healthy adults. Small children and anyone who is ill is not permitted to visit due to the client's immunocompromised status. Protective isolation interventions (e.g. having all visitors wear personal protective equipment) might be initiated as well. Incorrect Answers: A. hypoactive bowel sounds following an extensive burn and a nasogastric tube to suction should be kept NPO. Enteral feedings are often started to limit weight loss and complications of burns. Although the calorie requirements for clients who experience extensive burns can exceed 5,000 kcal/day, there is a decrease in gastrointestinal motility following a burn. To prevent weight loss, intestinal atrophy, and sepsis caused by the movement of bacteria from the intestines to the peritoneal space, nasoduodenal tube feedings are often administered. B. Maintaining mobility through the use of active and passive ROM exercises will decrease the risk of contracture development. The nurse should have the client perform ROM exercises independently or, if the client is unable, perform passive ROM exercises at least 3 times daily. C. Compression garments are designed to minimize scarring and contractures following a burn injury. They are measured specifically for the client and are applied after the grafts heal. At this stage of the client's recovery, compression garments should not be applied.
A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? • A. Blood urea nitrogen (BUN) • B. Blood glucose • C. Urineketones • D. Specific gravity
D. Specific gravity manifestation of diabetes insipidus. Incorrect Answers: A. BUN measures the ability of a client's kidney to excrete urea nitrogen B. Blood glucose is used to monitor a client who has diabetes mellitus and is not used to assess DI. C. Urine ketones are used to measure diabetic ketoacidosis and are not used to assess DI.
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)
D. Temperature of 39.1°C (102.4°F) SEPSIS TIME An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms. Incorrect Answers: A. Significant edema is expected when fluid shifts after a burn injury. B. Superficial partial-thickness and deep partial-thickness burns are painful throughout burn therapy. C. A urinary output of 30 mL/hr is within the expected reference range. A decrease in urine output is expected with edema and fluid shifts around the fourth day following a major burn injury.
A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign
Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately. Incorrect Answers: intracranial pressure. A. Battle's sign is bruising behind the ears and lower jaw that can occur from the trauma of a skull fracture. It does not indicate increased B. Periorbital edema is a result of facial trauma. It does not indicate increased intracranial pressure. D. A halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. The ring indicates leakage of cerebral spinal fluid that can occur with a skull fracture. It does not indicate increased intracranial pressure.
Clincal Clinical Manifestation of Brain Tumor include:
Seizure occur with metastases Hydrocephalus Increased ICP, cerebral edema Dull constant HDACHE that is worse at night N/V Memory altered, mood/personality changes Muscle weakness, sensory loss, aphasia, visual-spatial dysfunction Clinical S/S depend on tumor location, size
The RN 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 R pupil > L pupil E.Decorticate posturing to painful stimuli
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 VS would be an increased SBP with widening pulse pressure and bradycardia
Basal (battle ) Skull Fracture
basal skull fracture might include ecchymosis (discoloration of the skin resulting from bleeding) at the site of the mastoid process (battle signs) and/or around the periorbital area (raccoon eyes) CSF Leaking from eyes, ears, nose will have high amounts of glucose! If brain hits contacts cribriform plate (a small thin bone separated by tissue in the nasal cavity) --> patient at risk for serious infection --> encephalitis and meningitis. THINK ABX!!
Craniotomy vs Craniectomy:
both procedures involve removing a portion of the skull, the difference is that after a craniotomy the bone is replaced and after a craniectomy the bone is not immediately replaced. RN MGMT: PostOP: Monitor for pain, nausea LOC Assess surgical site (craniectomy), do not place patient on operative side
