NURS 405 - Unit 2

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer? - "I know that my father and my grandfather both had ulcers." - "The pain begins right after I eat." - "My pain resolves when I have something to eat." - "I seem to have bowel movements more often than I usually do."

- "My pain resolves when I have something to eat." Rationale: Pain relief after eating is associated with duodenal ulcers. This type of ulcer is not associated with family history or increased frequency of bowel movements. Pain immediately after eating is typical of gastric ulcers, not duodenal.

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client? - Anticonvulsant medications on day two of injury - Antiemetic medications on day three of injury - Intubation and ventilator support on day one of injury - Aspiration precautions on day four of injury

- Anticonvulsant medications on day two of injury Rationale: Clients with head injury are at an increased risk for posttraumatic seizures. Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure prophylaxis is the practice of administering anticonvulsant medications to clients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase ICP and decrease oxygenation. All of the other interventions are not part of the seizure prophylactic protocol nor have a specific timeline of administration.

A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority? - Start cardiopulmonary resuscitative measures - Assess the client's respiratory rate - Apply a heart monitor to the client - Determine how long the client was face down in the water

- Assess the client's respiratory rate Rationale: With a submersion injury, hypoxia is the primary problem. Therefore, assessment of airway and breathing are priority. Based on this assessment, the nurse would determine if resuscitative measures were needed. Other actions such as applying a heart monitor and obtaining additional information about the event would be done once the infant's airway and breathing are assessed and emergency interventions are instituted.

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? - Providing skin care with barrier care ointments once a day - Assisting the client to get out of bed to a chair four times a day. - Assessing all body surfaces and documenting skin integrity every 8 hours - Turning and repositioning the client every 6 hours

- Assessing all body surfaces and documenting skin integrity every 8 hours Rationale: Clients with TBI often require assistance in turning and positioning because of immobility or unconsciousness. Prolonged pressure on the tissues decreases circulation and leads to tissue necrosis. Specific nursing measures include the following: Assessing all body surfaces and documenting skin integrity every 8 hours. Turning and repositioning the client should occur every 2 hours. Skin care should be done every 4 hours and includes more than applying an ointment. Other interventions include keeping the skin dry, offloading bony prominences and with pillows or wedge devices. Since this client is unconscious; assisting the client to get out of bed needs his/her cooperation which is not possible. It should also be three times a day and not four.

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? - Bradycardia and hypertension - Respiratory distress and projectile vomiting - Tachycardia and agitation - Third-spacing and hyperthermia

- Bradycardia and hypertension Rationale: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? - Do not disturb the client between 2200 and 0600. - Administer a benzodiazepine at bedtime each night. - Ensure that the client does not sleep during the day. - Cluster overnight nursing activities to minimize disturbances.

- Cluster overnight nursing activities to minimize disturbances. Rationale: To allow the client longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the client is disturbed less frequently. However, it is impractical and unsafe to provide no care for an 8-hour period. The use of benzodiazepines should be avoided.

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. - Absence of deep tendon reflexes - Absence of pain response - Coma - Apnea - Absence of brain stem reflexes

- Coma - Apnea - Absence of brain stem reflexes Rationale: The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death.

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. - Contractures - Hemorrhage - Pressure ulcers - Venous thromboembolism - Pneumonia

- Contractures - Pressure ulcers - Venous thromboembolism - Pneumonia Rationale: Based on the assessment data, potential complications (partially based on immobility) may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. A persistent vegetative state does not directly create a heightened risk for hemorrhage.. A persistent vegetative state condition is when the client is wakeful but devoid of conscious content, without cognitive or affective mental function

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? - Recurrent constipation coupled with weight loss - Foul-smelling diarrhea that contains fat - Fever accompanied by a rigid, tender abdomen - Bloody bowel movements accompanied by fecal incontinence

- Foul-smelling diarrhea that contains fat Rationale: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? - Glasgow Coma scale - Mental status examination - Cranial nerve function - Monro-Kellie hypothesis

- Glasgow Coma scale Rationale: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this client, but would not be the priority in evaluating LOC. Glasgow coma scale can be done quickly and establishes a baseline of neurologic function.

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? - Tachycardia - Hyperthermia - Hypertension - Bradypnea

- Hyperthermia Rationale: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding? - Indications of increased intracranial pressure - An increase in the blood glucose level - A presence of protein in the urine - A decrease in the liver enzymes

- Indications of increased intracranial pressure Rationale: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme levels typically increase. Blood glucose levels and protein in the urine are not characteristic of this illness.

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? - Imbalanced nutrition: Less than body requirements related to impaired absorption - Ineffective tissue perfusion related to bowel ischemia - Anxiety related to bowel obstruction and subsequent hospitalization - vImpaired skin integrity related to bowel obstruction

- Ineffective tissue perfusion related to bowel ischemia Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.

A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? - Excessive stomach acid secretion - A metabolic acid-base imbalance - Infection with Helicobacter pylori - An incompetent pyloric sphincter

- Infection with Helicobacter pylori Rationale: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acid-base imbalances do not cause peptic ulcer disease.

A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? - Changing the rate of administration every 2 hours based on serum electrolyte values - Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance - Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body - Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possible

- Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance Rationale: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the client's fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual client based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? - Infusion of hypotonic IV solution - Administration of proton pump inhibitors as prescribed - Administration of antiemetics - Insertion of an NG tube for decompression

- Insertion of an NG tube for decompression Rationale: In treating the client with gastric outlet obstruction, the first consideration is to insert an NG tube to decompress the stomach. This is a priority over fluid or medication administration.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? - Oral phenytoin - Intravenous diazepam - Oral lorazepam - Intravenous phenobarbital

- Intravenous diazepam Rationale: Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, what would be most important for the instructor to integrate into the response? - Ischemic strokes are more common than hemorrhagic strokes. - Research has identified specific treatments for children. - The signs and symptoms in children are different from an adult. - Strokes in children often have an identifiable cause.

- Ischemic strokes are more common than hemorrhagic strokes. Rationale: In children, ischemic strokes are more common than hemorrhagic strokes. However, the cause of the stroke in many children remains unidentified. Signs and symptoms are similar to those in adults and will vary based on age; underlying cause, if known; and location of the stroke. Historically, children have been excluded from adult stroke studies and thus, many treatments used have had to be adapted from adult studies.

A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify what as the most common type of skull fracture in children? - Depressed - Diastatic - Linear - Basilar

- Linear Rationale: The most common type of skull fracture in children is a linear skull fracture, which can result from minor head injuries. Other, less common types of skull fractures in children include depressed, diastatic, and basilar.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? - Position the client supine. - Maintain head of bed (HOB) elevated at 30 to 45 degrees. - Maintain bed in Trendelenburg position. - Position client in prone position.

- Maintain head of bed (HOB) elevated at 30 to 45 degrees. Rationale: The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? - Insert a nasogastric tube promptly. - Reposition the client supine. - Monitor the client closely for further signs of dumping syndrome. - Assess the client for signs and symptoms of aspiration.

- Monitor the client closely for further signs of dumping syndrome. Rationale: The client's symptoms are characteristic of dumping syndrome, which results in a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Aspiration is a less likely cause for the client's symptoms. Supine positioning will likely exacerbate the symptoms and insertion of an NG tube is contraindicated due to the nature of the client's surgery.

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. What is the child's level of consciousness? - Confusion - Obtunded - Coma - Stupor

- Obtunded Rationale: Obtunded is a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful stimuli.

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all that apply. - Pneumothorax - Line sepsis - Hyperglycemia - Clotted or displaced catheter - Dumping syndrome

- Pneumothorax - Line sepsis - Hyperglycemia - Clotted or displaced catheter Rationale: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What nursing intervention(s) will the nurse complete to ensure safety during the examination? Select all that apply. - Assess for a latex allergy - Review any prescriptions for sedation - Place child in clothing with no metal - Connect the child to a heart monitor - Assess the IV site for patency

- Review any prescriptions for sedation - Place child in clothing with no metal - Assess the IV site for patency Rationale: When preparing a child for an MRI procedure, it is important the child and parent are aware of the test procedure. No metal can be used in the MRI scanner room so all clothing, jewelry, etc. need to be removed before testing. IV contrast may be used so the IV needs to be patent and in good working order. If the child is to be sedated the nurse should review the sedation prescription and identify any discrepancies before the child goes for the examination. If the child is to be sedated a heart monitor will be used, but it is not necessary for the nurse on the unit to connect the child. A special monitor compatible with the MRI scanner will be used. If sedated the child may also receive oxygen just as a prevention because the exam take a long time in a confined space. Having a latex allergy is not a contraindication for receiving gadolinium, the MRI contrast used during testing.

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? - Reports a history of social drinking on a weekly basis. - Consumes one or more protein drinks daily. - Takes over-the-counter antacids frequently throughout the day. - Smokes one pack of cigarettes daily.

- Smokes one pack of cigarettes daily. Rationale: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in clients with a history of consumption of alcohol on a daily basis.

A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? - Frequent urination - Fixed and dilated pupils - Sunlight is "too bright" - Sunset eyes

- Sunlight is "too bright" Rationale: Photophobia, or intolerance of light, is another symptom of bacterial meningitis. Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention. Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate increased intracranial pressure typical of hydrocephalus.

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? - Sudden thirst, unrelieved by oral fluid administration - Tachycardia, hypotension, and tachypnea - Tarry, foul-smelling stools - Diaphoresis and sudden onset of abdominal pain

- Tachycardia, hypotension, and tachypnea Rationale: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Clients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis.

A child is in the emergency department with a head injury obtained in a motor vehicle crash. The glascow coma scale assessment is rated at 10 (3 eye opening, 3 motor, 4 verbal). How should the nurse interpret these findings? - The child's eyes open spontaneously, able to localize pain and uses inappropriate words - The child's eyes open to pain, opens to extension and says incomprehensible words - The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli - The child's eyes open to speech, is able to obey commands but is confused

- The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli Rationale: The glascow coma scale is a widely used tool for assessing the extent of brain injury and prognosis. The scores are based on eye opening, motor response and verbal response. The perfect score is 15. The lower the score the more severe the injury and prognosis. Scores for a severe head injury are 8 or less. A moderate head injury scores between 9-12 points and a mild head injury scores between 13 and 15. With a score of 10 this child would be classified as having a moderate head injury. For answer B the eyes open spontaneously (4), localizes pain (5) and uses incomprehensive words(2) for a total score of 11.For answer C the eyes open to speech (3), uses inappropriate words (2) and has flexion withdrawal (4) for a total score of 9. For answer D the eyes open to pain (2) extremities open to extension (2) and uses incomprehensible words (2) for a score of 6.

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? - The client reports a headache. - The client is visibly fatigued. - The client reports pain at the site where the ball hits his head. - The client's speech is slightly slurred.

- The client's speech is slightly slurred. Rationale: Slurred speech would indicate a need for further assessment and observation due to the possibility of more serious trauma. Localized pain, a headache and fatigue are consistent with a concussion and do not necessarily require further intervention.

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. - Transcranial Doppler flow study - Cranial radiography - Electromyography (EMG) - Cerebral angiography - MRI

- Transcranial Doppler flow study - Cerebral angiography - MRI Rationale: Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.