NUR 240 - Final

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

D. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

A patient has developed DI after a head injury. Which medication should the nurse anticipate to be prescribed for the management of DI? A. Corticotrophin (Acthar) B. Octreotide (Sandostatin) C. Somatropin (Genotropin) D. Desmopressin (DDAVP)

D. Vasopressin (Pitressin) and desmopressin (DDAVP) are used to prevent or control polydipsia (excessive thirst), polyuria, and dehydration in patients with DI caused by a deficiency of endogenous antidiuretic hormone.

What is the priority nursing intervention in the postictal phase of a seizure? 1. Reorient the client to time, person, and place. 2. Determine the client's level of sleepiness. 3. Assess the client's breathing pattern. 4. Position the client comfortably.

3. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.

3. determine if the client is in cardiac arrest and then treat as v fib. If heart is beating, nurse would then administer lidocaine

Which of the following is not a typical sign and symptom of Cushing's Syndrome?* A. Hyperpigmentation of the skin B. Hirsutism C. Purplish striae D. Moon Face

A Hyperpigmentation is a typical sign of Addison's Disease

A nurse assesses a client who potentially has hyperaldosteronism. Which serum laboratory values should the nurse associate with this disorder? (SATA) a. Sodium: 150 mEq/L b. Sodium: 130 mEq/L c. Potassium: 2.5 mEq/L d. Potassium: 5.0 mEq/L e. pH: 7.28f. pH: 7.50

ACF Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. Hyponatremia, hyperkalemia, and acidosis are manifestations of adrenal insufficiency.

A patient with cerebral palsy has severe muscle spasticity and muscle weakness. The patient is unable to take anything by mouth. The nurse is correct to anticipate that which medication will be ordered for home therapy? a. Baclofen [Lioresal] b. Dantrolene [Dantrium] c. Diazepam [Valium] d. Metaxalone [Skelaxin]

ANS: A Baclofen is used to treat muscle spasticity associated with multiple sclerosis, spinal cord injury, and cerebral palsy. It does not reduce muscle strength, so it will not exacerbate this patient's muscle weakness. It can be given intrathecally, via an implantable pump, and therefore is a good choice for patients who cannot take medications by mouth. Dantrolene must be given by mouth or intravenously and so would not be a good option for this patient. It also causes muscle weakness. Diazepam is not the first-line drug of choice. Alternative routes to PO administration are IM, IV, or by rectum. Metaxalone is used to treat localized muscle spasms caused by injury and is not used for cerebral palsy.

The nurse is preparing to administer phenytoin (Dilantin) to a patient who has a seizure disorder. The patient appears drowsy, and the nurse notes that the last random serum drug level was 18 mcg/mL. What action will the nurse take? a. Administer the dose since the patient is not toxic. b. Contact the provider to discuss decreasing the phenytoin dose. c. Give the drug and monitor closely for adverse effects. d. Report drug toxicity to the providers.

ANS: A Drowsiness is a common side effect of phenytoin and is not cause for alarm. The patients drug level is normal, since 10-20 mcg/mL is the therapeutic range. The nurse should administer the dose. It is not necessary to decrease the dose or monitor the patient more closely than usual.

A client is bleeding from esophageal varices. The health care provider is arranging sclerotherapy for the client. Before the client goes to interventional radiology, the nurse prepares to administer which medication? a. Octreotide (Sandostatin) b. Enoxaparin (Lovenox) c. Lactulose (Heptalac) d. Spironolactone (Aldactone)

ANS: A Octreotide (Sandostatin) lowers BP in the liver, which decreases bleeding. Enoxaparin is a low-molecular-weight heparin, which would be contraindicated in a client with bleeding problems. Lactulose helps rid the body of ammonia. Aldactone is a diuretic.

The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Start a normal saline infusion. b. Give epinephrine (Adrenalin). c. Start continuous ECG monitoring. d. Give diphenhydramine (Benadryl).

ANS: B Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed

Insulin is used to treat hyperkalemia because it: a. Stimulates sodium to be removed from the cell in exchange for potassium. b. Binds to potassium to remove it through the kidneys. c. Transports potassium from the blood to the cell along with glucose. d. Breaks down the chemical components of potassium, causing it to be no longer effective.

ANS: C Insulin contributes to the regulation of plasma potassium levels by stimulating the Na+, potassium-adenosine triphosphatase (K+-ATPase) pump, thereby promoting the movement of potassium simultaneously into the liver and muscle cells with glucose transport after eating. The intracellular movement of potassium prevents an acute hyperkalemia related to food intake. The other options do not accurately describe how insulin is used to treat hyperkalemia

Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.

B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.

You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service: A. Hypoglycemia B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

B, C, D, and E. Anything that can cause an irritating stimulus below the site of the spinal injury (T6 or higher) can lead to autonomic dysreflexia, which causes an exaggerated sympathetic reflex response and the parasympathetic system is unable to oppose it. This will lead to severe hypertension. The most common cause of AD is a bladder issue (full/distended bladder, urinary tract infection etc). Other common causes are due to a bowel issue like fecal impaction or skin break down (pressure injury/ulcer, cut, infection etc.).

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? A. Obtain a 12-lead ECG and arterial blood gases. B. Rapidly administer 1000 mL normal saline solution IV. C. Administer norepinephrine (Levophed) by continuous IV infusion. D. Carefully insert a nasogastric tube and an indwelling bladder catheter.

B. Rapidly administer 1000 mL normal saline solution IV. Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.

In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury? A. Flushed lower body B. Pale and cool lower extremities C. Low blood pressure D. Absent reflexes

B. The lower extremities would be cool and pale due to vasconstriction caused by the exaggerated reflex response of the sympathetic nervous system from an irritating stimulus. The sympathetic reflex can NOT be unopposed by the parasympathetic nervous system due to the spinal injury, which is blocking the nerve impulse. The areas found ABOVE the site of injury would be flushed due to vasodilation from parasympathetic stimulation.

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

Correct Answer: C Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism

Correct Answer: 1,2,3 Rationale 1: One etiology of distributive shock is sepsis. 2: One etiology of distributive shock is spinal cord injury. 3: One etiology of distributive shock is anaphylaxis. 4: Hemorrhage is not an etiology of distributive shock. 5: Pulmonary embolism is not an etiology of distributive shock.

A 40-year-old male patient who was at the site of a workplace explosion that is considered a disaster area has suffered second- and third-degree burns to 65% of his body, but he is conscious. This person would be triaged as: A) Green B) Yellow C) Red D) Black

D The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. This patient is triaged as black

Assessment of an IV cocaine user with infective endocarditis should focus on which signs and symptoms (select all that apply) a. Retinal hemorrhages b. splinter hemorrhages c. presence of Osler's nodes d. Painless nodules over bony prominences e. painless erythematous macules on the palms and soles

a. Retinal hemorrhages b. splinter hemorrhages c. presence of Osler's nodes e. painless erythematous macules on the palms and soles Rationale: Clinical manifestations of infective endocarditis may include hemorrhagic retinal lesions (Roth's spots), splinter hemorrhages (black, longitudinal streaks) that may occur in the nail beds, Osler's nodes (painful, tender, red or purple, pea-size lesions) on the fingertips or toes, and Janeway's lesions (flat, painless, small, red spots) on the palms and soles.

A client is receiving digoxin and experiences severe bradycardia. which of the following would the nurse anticipate administering if prescribed a) Milrinone (Primacor) b) Atropine c) activated charcoal d) propafenone

b) Atropine

Which sign is characteristic of cardiac tamponade? a. SOB b. Beck's triad c. Holosystolic Murmur d. Bounding peripheral pulse

b. Beck's triad Beck's triad comprises 3 classic signs - elevated CVP with JVD, muffled heart sounds, and a drop in systolic BP.

The most important pathophysiologic factor contributing to the formation of esophageal varices is: a. Increased central venous pressure b. Portal hypertension c. Decreased albumin formation by the liver d. Decreased prothrombin formation

b. Portal Hypertension

The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder? a) Mitral insufficiency b) Tricuspid insufficiency c) Tricuspid stenosis d) Aortic regurgitation

d) Aortic regurgitation Explanation: The pulse pressure (i.e., difference between systolic and diastolic pressures) is considerably widened in patients with aortic regurgitation. One characteristic sign is the water-hammer (Corrigan's) pulse, in which the pulse strikes a palpating finger with a quick, sharp stroke and then suddenly collapses.

The client is admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site 2. Sudden onset of chest pain and frothy sputum 3. Foul smelling, concentrated urine 4. A reddened, inflamed central line catheter site

1. Signs and symptoms of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from every body orifice and into the tissues

The client has a right-sided chest tube. As the client is getting out of the bed it is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

1. The health-care provider will have to be notified, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. ***4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation. TEST-TAKING HINT: The word "first intervention" in the stem of the question indicates to the test taker that possibly more than one (1) intervention could be indicated in the situation but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.

The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has? 1. Drowsiness. 2. Inability to move. 3. Paresthesia. 4. Hypotension.

1. The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure.

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

1. This is incorrect information. It is the description of a spontaneous pneumothorax. 2. This is the description of an open pneumothorax. ***3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. 4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but it does not describe a tension pneumothorax. TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between "3" and "4," the test taker must go back to the stem and clarify what the question is asking.

A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? a) Assess the AV fistula for a bruit and thrill. b) Keep the AV fistula site dry. c) Take the client's blood pressure in the left arm. d) Keep the AV fistula wrapped in gauze.

A (The nurse needs to assess the AV fistula for a bruit and thrill because if these findings aren't present, the fistula isn't functioning. The AV fistula may get wet when the client isn't being dialyzed. Immediately after a dialysis treatment, the access site should be covered with adhesive bandages, not gauze. Blood pressure readings or venipunctures shouldn't be taken in the arm with the AV fistula.)

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? a) Risk for infection b) Impaired urinary elimination c) Toileting self-care deficit d) Activity intolerance

A (The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.)

For which dysrhythmia is defibrillation primarily indicated? A. Ventricular fibrillation B. Third-degree AV block C. Uncontrolled atrial fibrillation D. Ventricular tachycardia with a pulse

A. Ventricular fibrillation Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

A patient enters the ED presenting with symptoms of shortness of breath, severe chest pain, and diminished heart sounds. His blood pressure is 90/70 and his heart rate is 110. You notice that the trachea appears to be deviated to the right. What is your nursing priority? A) Prepare for an emergency insertion of a needle into the second intercostal space, midclavicular line B) Hang IV fluids and prepare for chest tube insertion C) Encourage patient to breathe into a paper bag and obtain ABG's. D) Assess for allergies and administer epinephrine as ordered

A This patient is presenting with symptoms of a tension pneumothorax. In this emergent situation, a needle can be inserted at the second intercostal space, midclavicular line to immediately allow some air to flow out of the pleural space. A chest tube would then be inserted. The lung re-expansion would correct the abnormal blood pressure and heart rate, and the patient does not appear to be having an allergic reaction.

An indication of Chvostek' sign is: A. Twitching of the lips after tapping the face B. Elevated blood sugar after glucose infusion C. Inability to hold one's arms straight D. Spasms of the hand after blood circulation is cut off

A Twitching of the lips after tapping the face in the right place is an indication of Chvostek's sign and a sign of hypocalcaemia. Spasms of the hand are associated with Trousseau's sign.

A nurse on a sixth floor medical surgical unit is advised that a severe weather alert code has been activated. Which of the following actions should the nurse take? (select all that apply) A. Draw window shades and close drapes as protection against shattering glass B. Move beds of nonambulatory clients away from windows C. Relocate ambulatory clients into the hallways D. Use the elevators to move clients to lower levels E. Turn the radio on for severe weather warnings

A, B, C, E

Patient education regarding a fistulae or graft includes which of the following? Select all that apply. a) Check daily for thrill and bruit. b) No IV or blood pressure taken on extremity with dialysis access. c) Cleanse site b.i.d. d) Avoid compression of the site. e) No tight clothing.

A, B, D, E (The nurse teaches the patient with fistulae or grafts to check daily for a thrill and bruit. Further teaching includes avoiding compression of the site; not permitting blood to be drawn, an IV to be inserted, or blood pressure to be taken on the extremity with the dialysis access; not to wear tight clothing, carry bags or pocketbooks on that side, and not lie on or sleep on the area. The site is not cleansed unless it is being accessed for hemodialysis.)

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Overwhelming fatigue should be avoided. B. Caffeinated products should be removed from the diet. C. Looking at flashing lights should be limited. D. Aerobic exercise may be performed. E. Episodes of hypoventilation should be limited. F. Use of aerosol hairspray is recommended.

A. Correct: The nurse should instruct the client to avoid overwhelming fatigue, which may trigger a seizure by stimulating abnormal electrical neuron activity. B. Correct: The nurse should instruct the client to remove caffeinated products from the diet, which may trigger a seizure by stimulating abnormal electrical neuron activity. C. Correct: The nurse should instruct the client to refrain from looking at flashing lights, which may trigger a seizure by stimulating abnormal electrical neuron activity. D. Incorrect: The nurse should instruct the client to decrease physical activity, which may help to avoid triggering a seizure. E. Incorrect: The nurse should instruct the client to limit excess hyperventilation, which may trigger a seizure by stimulating abnormal electrical neuron activity. F. Incorrect: The nurse should instruct the client to avoid using aerosol hairspray, which may trigger a seizure by stimulating abnormal electrical neuron activity.

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin (Dilantin).Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication

A. Incorrect: The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin. B. Incorrect: The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. Correct: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. Incorrect: The nurse should instruct the client to have period blood tests to determine the therapeutic level of phenytoin.

What is the BEST position for a patient experiencing autonomic dysreflexia? A. High Fowler's with legs lowered B. Low Fowler's with legs lowered C. Semi-Fowler's with legs at heart level D. Prone

A. The patient should be in high Fowler's (90 degrees) with the legs lowered. This will allow gravity to cause blood to pool in the lower extremities and help decrease blood pressure.

The nurse understands adenosine (Adenocard) is used to treat which condition? A. Atrial fibrillation B. Second-degree atrioventricular block C. Paroxysmal supraventricular tachycardia (PSVT) D. Atrial flutter

C.

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? A. Insulin infusion B. IV administration of epinephrine C. Aggressive IV crystalloid fluid resuscitation D. Administration of nitrates and β-adrenergic blockers

C. Aggressive IV crystalloid fluid resuscitation Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).

You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST? A. Reassess the patient's blood pressure. B. Check the patient's blood glucose. C. Position the patient at 90 degrees and lower the legs. D. Provide cooling blankets for the patient.

C. Based on the patient findings and how the patient has a spinal cord injury at T6, they are experiencing autonomic dysreflexia. Patients with this condition may have a blood pressure that is 20-40 mmHg higher than their baseline and may experience bradycardia (heart rate less than 60). The FIRST action the nurse should take when AD is suspected is to position the patient at 90 degree (high Fowler's) and lower the legs. This will allow gravity to cause the blood to pool in the lower extremities and help decrease the blood pressure. Then the nurse should try to find the cause of the autonomic dysreflexia, which could be a full bladder, impacted bowel, or skin break down.

In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms

C. tPa dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.

Correct Answer: D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.

On physical assessment of a patient with pericarditis, you may hear what type of heart sound? A. S3 or S4 B. mitral murmur C. pleural friction rub D. pericardial friction rub

D

During a mass casualty, which injury receives care first? a. Abdominal evisceration b. Open fracture of the left forearm c. Sprained ankle d. Sucking chest wound

D (This casualty is a red tag, or emergent, because it can be quickly resolved until further help can be given.)

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a) Pregabalin (Lyrica) b) Diphenhydramine (Benadryl) c) Heparin d) Lioresal (Baclofen)

Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

You are developing a care plan for a patient with SIADH. Which of the following would be a potential nursing diagnosis for this patient? A. Fluid volume overload B. Fluid volume deficient C. Acute pain D. Impaired skin integrity

The answer is A: Fluid volume overload

A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly "water" weight. In addition, they report the patient hasn't been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient's HR is 115 and BP 180/92. Patient sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with? A. SIADH B. Diabetes Insipidus C. Addison's Disease D. Fluid Volume Deficient

The answer is A: SIADH

On auscultation, the nurse suspects a diagnosis of mitral valve stenosis when which of the following is heard? a) Low-pitched, rumbling diastolic murmur at the apex of the heart b) High-pitched blowing sound at the apex c) Mitral valve click d) Diastolic murmur at the left sternal border of the heart

a) Low-pitched, rumbling diastolic murmur at the apex of the heart. The murmur is caused by turbulent blood flow through the abnormally tight valve opening. A low-pitched, rumbling, diastolic murmur (heard on S2) is heard best at the apex. A loud S1, due to abrupt closure of the mitral valve, and an early diastolic opening snap can be heard. The snap is the premature opening of the stenotic mitral valve.

Which statements accurately describe thrombocytopenia (select all that apply)? a. Patients with platelet deficiencies can have internal or external hemorrhage. b. The most common acquired thrombocytopenia is thrombotic thrombocytopenic purpura (TTP). c. Immune thrombocytopenic purpura (ITP) is characterized by increased platelet destruction by the spleen. d. TTP is characterized by decreased platelets, decreased RBCs, and enhanced aggregation of platelets. e. A classic clinical manifestation of thrombocytopenia that the nurse would expect to find on physical examination of the patient is ecchymosis.

a, c, d. Immune thrombocytopenic purpura (ITP) is characterized by increased platelet destruction by the spleen. Thrombotic thrombocytopenic purpura (TTP)has decreased platelets and RBCs with enhanced agglutination of the platelets. Platelet deficiencies lead to superficial site bleeding. ITP is the most common acquired thrombocytopenia. Petechiae, not ecchymosis, is a common manifestation of thrombocytopenia.

The patient with diabetes insipidus is brought to the emergency department with confusion and dehydration after excretion of a large volume of urine today even though several liters of fluid were drunk. What is a diagnostic test that the nurse should expect to be done to help make a diagnosis? a. Blood glucose b. Serum sodium level c. Urine specific gravity d. Computed tomography (CT) of the head

c. Patients with diabetes insipidus (DI) excrete large amounts of urine with a specific gravity of less than 1.005. Blood glucose would be tested to diagnose diabetes mellitus. The serum sodium level is expected to be low with DI but is not diagnostic. To diagnose central DI a water deprivation test is required. Then a CT of the head may be done to determine the cause. Nephrogenic DI is differentiated from central DI with determination of the level of ADH after an analog of ADH is given.

When teaching a patient with endocarditis how to prevent recurrence of the infection, the nurse instructs the patient to a. start on antibiotic therapy when exposed to persons with infections b. take one aspirin a day to prevent vegetative lesions from forming around the valves c. always maintain continuous antibiotic therapy to prevent the development of any systemic infection d. obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures (e.g. dental cleaning)

d. obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures (e.g. dental cleaning)Rationale: Prophylactic antibiotic therapy should be initiated before invasive dental, medical, or surgical procedures to prevent recurrence of endocarditis. Continuous antibiotic therapy is indicated only in patients with implanted devices or ongoing invasive procedures. Symptoms of infection should be treated promptly, but antibiotics are not used for exposure to infection.

Treatment for myocarditis (info from powerpoint)

•Antibiotics •Antiviral therapy with interferon-a •Corticosteroids •Bed rest and activity restrictions for as long as 6 months •No NSAIDS