Exam 3 EAQ

Initially, after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is rising. Which complication would the nurse plan to address? Spinal Shock Hypovolemic Shock Transtentorial Herniation Increased ICP

Increased ICP Spinal shock - hypotensive with no pupillary changes hypovolemic shock - hypotensive and tachy, no changes in pupillary reaction transtentorial herniation - dilated pupils and severe posturing

which health history problem would increase an older adult's risk for experiencing a CVA? glaucoma hypothyroidism continuous nervousness, stress TIAs

TIAs

which instruction about phenytoin will the nurse provide during discharge teaching to a client with epilepsy who is prescribed phenytoin for seizure control? antiseizure meds will probably be continued for life phenytoin prevents any further occurrence of seizures this medication needs to be taken during periods of emotional stress your antiseizure medication usually can be stopped after a year's absence of seizures

antiseizure medications will probably be continued for life - absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiological condition

battle sign is seen in what type of fracture

basilar fracture battle sign indicates bleeding in the middle cranial fossa - where pituitary gland sits

which physical assessment finding would the nurse document on a client who is experiencing Cushing triad? select all that apply bradycardia tachycardia irregular respirations systolic hypertension diastolic hypertension widening pulse pressure

bradycardia (with full bounding pulse) irregular respirations widening pulse pressure -which would mean systolic hypertension and diastolic hypotension ICP >20mmHg

which instructions would the nurse include at the time of discharge for a child who has been diagnosed with a mild concussion? withhold food and fluids for 24 hrs encourage outdoor play and visits with friends arrange for a follow-up visit with the PCP check for changes in responsivenss every 2 hrs for 2 days

check for changes in responsiveness every 2hrs for 2 days

which client who sustained injuries in an accidental fire would be provided with immediate care based on priority? client with burns to head client with burns in chest area client with burns in LEs client with burns in UEs

client with burns to head - airway

which clinical indicator suggests to the nurse that a client may be experiencing a complication of fractured ribs? report of pain taking deep breaths client is observed splinting the fracture site diminished breath sounds on the affected side bowel sounds are auscultated in lower chest

diminished breath sounds on affected side - fractured ribs may penetrate the pleura and lung, allowing air (pneumothorax) to enter pleural space and collapse the lung

Which mechanism of action is responsible for the therapeutic effects of mannitol prescribed for a client with a head injury? decreasing the production of CSF limiting the metabolic requirements of the brain drawing fluid from brain cells into bloodstream preventing uncontrolled electrical discharges in the brain

drawing fluid from brain cells into the bloodstream - uses osmosis

which type of burn injury should be followed up by scheduling the client for an ECG? flame burn chemical burn electrical burn radiation burn

electrical burn - may damage heart - also maintain C-spine precautions until ruled out

for which client condition would the nurse stabilize the cervical spine as the priority nursing intervention? select all that apply flail chest head injuries facial chemical burns renal colic pain blunt abdominal pain

flail chest head injuries facial chemical burns all affect respiratory distress

A client arrives in the ED unconscious and exhibiting decerebrate posturing. Which positioning behaviors would the nurse expect to observe? hyperextension of both upper and lower extrem spastic paralysis of both upper and lower extrem hyperflexion of the upper extrem and hyperextension of the lower extrem flaccid paralysis of the upper extrem and spastic paralysis of the lower extrem

hyperextension of both the upper and lower extrem - limbs are hyperextended and arms are hyperpronated - away from body indicates upper motor neuron disease or lesion (ponds and medulla) decorticate - core - flexion posturing

the nurse is caring for a 6 year old child who has undergone a craniotomy. the parent ask what effect mannitol has. which response by the nurse is most appropriate? it relieves cerebral pressure increases bladder's filtration rate reduces glucose excretion in kidneys decreases peripheral retention of fluid

it relieves cerebral pressure

the nurse would utilize the GCS on a trauma client to complete which assessment? patency of airway level of consciousness breathing abnormalities circulatory abnormalities

level of consciousness

Which clinical finding is consistent with an increase in ICP? thready, weak pulse narrowing pulse pressure regular, shallow breathing lower level of consciousness

lowered level of consciousness - first sign of increased ICP as ICP increases, then pulse would then widening pulse pressure irregular breathing occurs with ICP >20 - Cushing's Triad

Which action would the nurse take when caring for a client who has a possible skull fracture as a result of trauma? monitor the client for sxs of brain injury check for hemorrhaging from oral cavity elevate foot of the bed if client if the client develops sxs of shock observe for indicators of decreased intracranial pressure and temperature

monitor the client for sxs of brain injury - increased ICP (headache, dizziness, visual changes) checking for hemorrhaging from oral cavity is not indicated elevating the LEs would be avoided because it will increase ICP

Which interventions would be a priority for the nurse to include in the plan of care for a client with a gunshot wound who has severe hemiplegia associated with abnormal body posturing and fixed dilating pupils? monitoring skin integrity monitoring bowel patterns monitoring respiratory rate monitoring nutritional status

monitoring respiratory rate signs of hemorrhagic shock

which condition would the nurse suspect in an ED client with C8 tetraplegia, BP 80/40mmHg, pulse of 48 beats per min, and RR 18 breaths a minute? autonomic dysreflexia hemorrhagic shock neurogenic shock pulmonary embolism

neurogenic shock - hypotensive and brady - injury is above T6

which nursing action would the nurse implement immediately when providing care to a trauma client whose primary survey indicates a GCS score of 7? prepare for intubation observe for chest wall trauma cover client with a blanket apply direct pressure to client's wound

prepare for intubation

which nursing action is appropriate for a pt during the tonic-clonic stage of a seizure? go for additional help establish patent airway restrain client to prevent injury protect client's head from injury

protect client's head from injury airway established after seizure

which specific emergency burn mgmt would be appropriated for a client received in the ED with burns caused by flames? removing all metal objects helping the client bathe or shower initiating cardiopulmonary resuscitation administering tetanus toxoid for prophylaxis

removing all metal objects - can cause further burns showering - for radiation burns CPR - most likely for electrical burns tetanus - for any 3rd degree burn or greater

which type of burns would the nurse assessing burn injuries identify on fire survivors with pink to cherry-red with blisters? first degree second degree third degree fourth degree

second degree first - no blisters second - pink, painful, blister third and fourth - dry and lethary skin with impaired sensation when touched (painless)

Which assessment finding after an open reduction and internal fixation (ORIF) of a fractured hip would cause the nurse to suspect and monitor for sxs of a fat embolism? fever and chest pain positive Homan's sign loss of sensation in operative leg tachycardia and petechiae over the chest

tachycardia and petechiae over the chest tachy dt impaired gas exchange petechiae dt occlusion of small vessels within the skin Homan's sign = thrombophlebitis

a client in the second (acute) phase of burn recovery may exhibit an increase in which value? serum sodium urinary output hematocrit level serum potassium

urinary output - as fluid returns to vascular system, increased renal flow and DIURESIS occur K+ would decrease in this phase as fluid goes back until the cells (permeability normalizes)

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure? Select all that apply vomiting irritability hypotension increased respirations decreased LOC

vomiting - dt pressure on brain irritability - dt pressure on brain decreased LOC BP would be INCREASED dt pressure on vital centers on brain Respirations would be DECREASED - cheyne-stokes resp as ICP increases