GB, MG, Anaphylaxis

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex .e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

A, B, C, E, F

5. Which complications may manifest after an electrical injury? (Select all that apply.) a.Long bone fractures b.Cardiac dysrhythmias c.Hypertension d.Compartment syndrome of extremities e.Dark brown urine f.Peptic ulcer disease g.Acute cataract formation h.Seizures

A, B, D, E, G, H

The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) A. Blood pressure B. Heart rate C. Level of consciousness D. Pupil response E. Respirations F. Urine output

A, C, F

10. What is the antidote for Tensilon?

Atropine

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.) a. Use of a heparin flush solution b. Manually flushing the device "prn" c. Recording ICP as a "mean" value d. Use of a pressurized flush systeme. Zero referencing the transducer system

C, E

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) A. Administer acetaminophen. B. Document the patient's response. C. Increase the rate of transfusion. D. Notify the blood bank. E. Notify the provider. F. Stop the transfusion.

D, E, F

9. What is the role of plasmapheresis in the client with GBS?

Removes circulating antibodies thought to be responsible for the problem

Which of the following statements about the pain management of a burn victim are true? (Select all that apply.) a.Additional pain medication may be needed because of rapid body metabolism. b.Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c.Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d.The intramuscular route is preferred for pain medication administration.

a, b, c

Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infection and sepsis secondary to central line catheters c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

a, b, c,

6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.) a.involves a joint. b.involves the face, hands, or feet. c.is infected. d.requires more than 2 weeks for healing.

a, b, d

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. Administration of fresh frozen plasma as ordered c. Administration of potassium as ordered d. Administration of calcium as ordered e. Monitoring CBC and coagulation studies

a, b, d

The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a.Applying splints that maintain the extremity in an extended position b.Implementing passive or active range-of-motion exercises c.Keeping the limbs as immobile as possible d.Wrapping fingers and toes individually with bandages

a, b, d

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.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration.e. Restrain affected limb to prevent injury.

a, c

During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air e. Paradoxical chest wall movement

a, c, d

Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.) a. Mean arterial pressure 48 mm Hg b. Elevated serum blood alcohol level c. Nonreactive pupils d. Respiratory rate of 10 breaths/min e. Open skull fracture

a, c, d, e

Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a.Apply topical antibacterial wound ointments/dressings. b.Change indwelling urinary catheter every 7 days. c.Daily assess the need for central IV catheters d.Restrict family visitation. e.Maintain strict aseptic technique during burn wound management.

a, c, e

3. Which should be included in health care teaching for the GBS client? a. Always include a family member or significant other. b. Instructions are given in oral form only. c. Always include information on range-of-motion exercises. d. Include information on the need for continued plasmapheresis.

a. Always include a family member or significant other.

The trauma nurse understands which information related to the older trauma patient? (Select all that apply.)a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension.d. Chronic diseases do not have much effect on the older trauma patient.e. Fractures to bones other than hips are uncommon from trauma.

a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome .c. Hypotension in the elderly can appear as normotension.

Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully crossmatched blood products are administered. e. Hypertonic saline solutions are often used during initial resuscitation.

b, c

t is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction e. Fat embolism

b, c, d

Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.) a.Burn injury less than 10% b.Bedrest c.Burns to lower extremities d.Electrical burn injury e.Delayed fluid resuscitation

b, c, e

The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.)a. Whole blood b. Universal donor blood only c. Red blood cells d. Plateletse. Plasma

c, d, e

Which of the following would the nurse report to the physician immediately for a client with GBS? a. Increasing loss of motor function b. Ineffective cough c. Dyspnea and confusion d. Analgesia following administration of opioids

c. Dyspnea and confusion

. Which of the following symptoms of an MG client should the nurse report to the physician immediately? a. Diarrhea b. Blurry vision c. Inability to swallow d. tinnitis

c. Inability to swallow

6. In planning activities for the client with MG, the nurse should use which of the following parameters? a. Time of day b. Severity of symptoms c. Medication times d. Sleep schedule

c. Medication times

4. Which of the following statements about Tensilon testing is correct? a. A false-positive test may occur if the muscle is extremely weak. b. The drug has a long duration of action. c. The test can be used to distinguish between a cholinergic crisis and

c. The test can be used to distinguish between a cholinergic crisis and

2. Which of the following statements about treatment for GBS is correct? a. Immunoglobulins are curative. b. Second treatments with plasmapheresis have increased risk of side effects. c. Treatment is supportive because this disease is usually self-limiting. d. Immunoglobulins have no major side effects.

c. Treatment is supportive because this disease is usually self-limiting.

7. Which of the following is important information about MG drug therapy? a. If a dose of cholinesterase is missed, a double dose is taken the next day. b. Antibiotics such as neomycin and kanamycin have a synergistic effect with cholinesterase inhibitors. c. Medications must be taken on an empty stomach. d. Drugs containing morphine or sedatives can increase muscle weakness.

d. Drugs containing morphine or sedatives can increase muscle weakness.

11. What is the role of anticholinesterase drugs such as Mestinon or Regonol In the treatment of MG?

relieve symptoms

. What are the most life threatening complications of Guillain Barre' Syndrome

respiratory failure