B2
Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following are causes of secondary brain injury? Select all that apply.
Cerebral edema Seizures Infection Ischemia Hyperthermia
The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.)
Recording ICP as a mean value Zero referencing the transducer system
Which of the following laboratory values would be more common in patients with diabetic ketoacidosis?
pH 7.24
While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak?
18 to 36 hours
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?
An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza
The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action?
CVP of 2 mm Hg
Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.)
Heredity Medications Sickle cell disease
Nursing care for a client in Addisonian crisis should include which intervention?
Placing the client in a private room
Which of the following are the immediate complications of spinal cord injury?
Respiratory arrest Spinal shock
A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?
allodynia
A nurse is caring for a client with suspected hyperparathyroidism. Which condition may contribute to hyperparathyroidism?
renal failure
Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?
transcranial doppler
A patient is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer?
A proton pump inhibitor
The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse?
Administer over 20 to 30 minutes.
A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:
Loss of motor power and sensation in the upper extremities.
Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.)
Open skull fracture Nonreactive pupils Respiratory rate of 10 breaths/min Mean arterial pressure 48 mm Hg
What nursing intervention will best help the client with Huntington disease to increase nutrition? Select all that apply.
Take phenothiazine prior to meals Use relaxation techniques
Acute adrenal crisis is caused by
deficiency of corticosteroids
The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.)
29-year-old female who is undergoing evaluation for pheochromocytoma 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)
The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the provider prescriptions, which order is of the highest priority?
500 mL albumin intravenous infusion
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.
Absence of brainstem reflexes Apnea Coma
A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.)
Blood glucose 524 mg/dL HCO3 10 mEq/L pH 7.23
Thyroid storm is a severe form of hyperthyroidism that can be fatal if not treated. Medical management includes pharmacotherapy. Which of the following drugs have proved helpful? Select all that apply.
Hydrocortisone Acetaminophen Methimazole Iodine
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?
Increased cerebral blood volume due to vessel dilation
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury?
It results from inadequate delivery of nutrients and oxygen to the cells.
The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.)
Maintain MAP less than 130 mm Hg. Make frequent neurological assessments.
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first?
Mannitol 1 g intravenous
A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?
No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
client 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 client? Select all that apply.
Orthostatic hypotension Autonomic dysreflexia DVT
The nurse is caring for a client postoperatively from a spinal tumor resection. The nurse assesses that the client has partial paralysis. What anticipated problems should the nurse include in the client's care plan? Select all that apply.
Risk for injury Risk for powerlessness Risk for knowledge deficit Risk for impaired physical mobility
In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started?
When the blood glucose reaches 250 mg/dL
A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with:
depression
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?
epidural
Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?
fluid volume deficient
The greatest risk of seizures for clients with brain tumors occurs in those who have tumors in which regions of the brain? Select all that apply.
frontal, parietal, temporal
A patient whose laboratory studies indicates a prolactin level of 200 ng/mL is assessed for a pituitary tumor. During the physical exam, the nurse practitioner notices a number of signs and/or symptoms suggestive of this condition. Which of the following is the most common indicator of a pituitary tumor?
galactorrhea
The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage?
hyperthermia
In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.)
Presence of cervical injuries is a contraindication to the assessment of this reflex. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. Doll's eyes present indicate brainstem activity. Doll's eyes absent indicate a disruption in normal brainstem processing. Eye movement in the opposite direction as the head when turned indicates an intact reflex.
A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time?
Propofol (Diprivan)
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)?
Reduce ambient room temperature and administer antipyretics.
Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone?
Serum sodium of 115 mEq/L
The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse?
The patient is developing neurogenic shock.
Which of the following statements to the Type 2 Diabetic patient by the nurse is correct?
Try to wear closed toe shoes whenever ambulating.
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply.
Venous pooling Hypothermia Hypotension Tachycardia
The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first?
500 mL albumin infusion intravenously
A client with a brain tumor is experiencing changes in cognition that require the nurse to reorient the client frequently. When performing this task, which devices would be appropriate for the nurse to use? Select all that apply.
Client's clothing Picture of the client's family Clock Calendar
Which of the following symptoms would a patient exhibit with hyperthyroidism?
None of the above
The nurse is caring for a client who is currently under medical investigation for a pituitary adenoma. The nurse anticipates the client will likely report which symptoms that are consistent with this type of brain tumor? Select all that apply.
Polydipsia Polyuria Disturbed sleep Impairment of visual field
The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing
diabetes insipidus.
A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of:
diabetic ketoacidosis.
