Quiz questions from weeks 12, 13, 14

A patient with intracranial pressure monitoring in place has an ICP of 15 mm Hg. The nurse understands that this pressure reflects what? 1. A normal balance between brain tissue, blood, and cerebrospinal fluid 2. The loss of autoregulation of intracranial pressure due to decompensation 3. An increase in the production of cerebrospinal fluid due to injury 4. A severe decrease in cerebral tissue perfusion due to swelling

1. A normal balance between brain tissue, blood, and cerebrospinal fluid

A patient with a forearm fracture is informed that fracture union is occurring by the presence of what on the x-ray? 1. The presence of hard callus 2. The presence of soft callus 3. The presence of a hematoma 4. The presence of granulation tissue

1. The presence of hard callus

A patient with a comminuted fracture of the femur is scheduled to have an open reduction with internal fixation (ORIF) of the fracture. An ORIF is indicated when: 1. adequate alignment cannot be obtained by other non-surgical procedures 2. the patient is unable to tolerate prolonged immobilization by traction 3. a temporary cast would be too unstable to provide normal mobility 4. the patient does not have good results from closed reduction

1. adequate alignment cannot be obtained by other non-surgical procedures

The presence of Neurogenic Shock is recognized by which manifestations? Select all that Apply 1.Peripheral Vasodilation 2.Decreased reflexes 3.Flaccid paralysis 4.Hypotension 5.Bradycardia

1.Peripheral Vasodilation 4. Hypotension 5. Bradycardia

The nurse understands the important brain function of autoregulation. Based on the nurse's knowledge of autoregulation which statements are correct? Select all that apply 1. The brain loses the ability to autoregulate when the ICP falls below 10 2. Autoregulation is the brain's ability to regulate its blood flow in response to metabolic needs 3. Autoregulation is effective when the MAP is 50mmHg - 150mm Hg 4. The diameter of the cerebral blood vessels changes in response to blood pressure to maintain blood flow 5. A MAP > 150 mm Hg improves autoregulation and increasing blood flow

2. Autoregulation is the brain's ability to regulate its blood flow in response to metabolic needs 3. Autoregulation is effective when the MAP is 50mmHg - 150mm Hg 4. The diameter of the cerebral blood vessels changes in response to blood pressure to maintain blood flow

A 39-year-old male suffers a severe brain injury when he falls off a roof while working. A CT scan reveals that he has a basilar skull fracture. Based upon his injuries, what specific manifestation should the nurse observe for in this patient? 1. Changes in the patient's LOC and pupils 2. Cerebral spinal fluid leak from the nose 3. Increased intracranial pressure over the normal value 4. Hematoma formation at the point of injury

2. Cerebral spinal fluid leak from the nose

A patient arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the dura mater and the arachnoid layer. Which type of head injury does this finding suggest? 1. Epidural hematoma 2. Subdural hematoma 3. Contusion 4. Subarachnoid hemorrhage

2. Subdural hematoma

A patient with a C 5 spinal cord injury (SCI) has total loss of sensation and movement of the upper and lower extremities below the level of injury, as well as bowel and bladder dysfunction. Which term correctly describes this type of injury? 1. Complete Paralpegia 2. Incomplete tetraglegia 3. Complete Tetralpegia 4. Complete Hemiplegia

3. Complete Tetralpegia

The patient was an unrestrained front-seat passenger in a motor vehicle crash and struck his forehead on the inside of the windshield. Diagnostic testing in the emergency department reveals coup-contrecoup injury. The nurse identifies which area as the contrecoup injury? 1. Both the anterior and posterior areas of the brain 2. The midpoint of the brain stem 3. The posterior or occipital part of the brain 4. The frontal area of the brain

3. The posterior or occipital part of the brain

A patient is hospitalized for a fractured femur following a motorcycle accident. Two days after being admitted, the patient new confusion and complains of chest pain and dyspnea. Further manifestations include tachycardia and petechiae that is present on his neck and chest. The manifestations are indicative of: 1. compartment syndrome 2. pulmonary edema 3. fat embolism syndrome 4. early ARDS

3. fat embolism syndrome

A patient arrives to the ED after falling from an ATV that struck a tree. The family reports that they witnessed the crash and that the patient was unconscious at the scene. The patient remains unconscious and displays posturing when stimulated. The nurse recognizes that this is what type of brain injury? 1. A diffuse concussion injury 2. A retrograde amnesiac injury 3. A focal head injury 4. A diffuse axonal injury

4. A diffuse axonal injury

Which of the following signs and symptoms of increasing ICP after head trauma will manifest first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Widening pulse pressure 4. Change in level of consciousness

4. Change in level of consciousness

The nurse is taking care of a patient with a spinal cord injury at the level of L1. Which of the following findings is expected for this patient? 1. Loss of sensation in the fingers and toes 2. Inability to move arms 3. Difficulty breathing 4. Dysfunction of the bowel and bladder

4. Dysfunction of the bowel and bladder

Decerebrate posturing is present in an unconscious patient following a motor vehicle accident. The nurse expects to see which positioning demonstrated by the patient? 1. The arms and legs have tonic-clonic seizure activity 2. The arms are pulled inward and the head is turned to the side 3. The arms are folded over the chest with spasms that are rhythmic 4. The arms are hyper-extended and hyper-pronated with hyperextension of the legs

4. The arms are hyper-extended and hyper-pronated with hyperextension of the legs

A hospital client with a diagnosis of acute liver failure has been prescribed a low dose of spironolactone in order to treat ascites. The nurse who is providing this client's care should prioritize assessments for the signs and symptoms of what health problem? A. Hepatic encephalopathy B. Peritonitis C. Cirrhosis D. Liver cancer

A. Hepatic encephalopathy

A client is experiencing hepatorenal syndrome. Which manifestations will the nurse assess in this client? Select all that apply. A. Oliguria B. Ascites C. Polyuria D. Increased serum creatinine E. Azotemia

A. Oliguria B. Ascites D. Increased serum creatinine E. Azotemia

A client is brought to the emergency department with a suspected diagnosis of DKA (diabetic ketoacidosis). Select the assessment data (or diagnostic data) to confirm the diagnosis. Select all that apply. A.Serum bicarbonate that is low - < 15 mmol/L B.Negative serum ketones C.Blood Glucose level > 250 mg/dL D.Positive urine and serum ketones E.High arterial pH

A.Serum bicarbonate that is low - < 15 mmol/L C.Blood Glucose level > 250 mg/dL D.Positive urine and serum ketones

A patient presents with hip pain after a fall. A focused assessment is needed to detect the specific manifestations that indicate to the nurse that the injury may be a hip fracture. Select all that apply 1. Shortening of the affected limb 2. Internal rotation of the affected limb 3. External rotation of the affected limb 4. Report of pain in the affected leg 5. Report of numbness of the affected leg

ASK

A patient with an incomplete spinal cord injury (SCI) is most likely to experience which of the following? 1. Restoration of sensory function first 2. Only a mild motor movement deficiency 3. Some neurotransmission of impulses 4. A good prognosis for recovery

ASK

Right upper quadrant pain, possible excess bleeding, watch closely for encephalopathy

Acute Liver Failure

Which client on a hospital medical unit is most clearly demonstrating the signs and symptoms of liver failure? A. 68-year-old female client with sudden onset of confusion, a history of alcohol abuse, and low levels of serum AST and ALT B. 44-year-old man with low hemoglobin levels, low platelet levels, and spider angiomas present C. 55-year-old man with ascites, fever, and recent onset of atrial fibrillation D. 50-year-old woman with blood pressure of 189/103, jaundice, and multiple thromboses

B. 44-year-old man with low hemoglobin levels, low platelet levels, and spider angiomas present

The educator is explaining the causes of pancreatitis to the student nurse. Which explanation is correct? A. Fluid volume deficit leads to poor tissue perfusion and lactic acidosis. B. Gallstones or inflammation may obstruct the pancreatic duct or cause bile reflux, activating pancreatic enzymes in the pancreatic duct system. C. Disrupted blood flow through the liver leads to portal hypertension affecting the pancreas. D. Decreased levels of calcium from kidney disease lead to pancreatitis.

B. Gallstones or inflammation may obstruct the pancreatic duct or cause bile reflux, activating pancreatic enzymes in the pancreatic duct system.

A client develops diabetic ketoacidosis. What assessment indicates compensatory action? A. Facial rubor with dry skin B. Respirations deep at 30/min C. Mental sluggishness D. Urinary output 400 mL in 2 hrs

B. Respirations deep at 30/min

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this? A. Muscle pain related to referred pain manifestations B. Muscle spasm related to hypokalemia C. Tetany related to hypocalcemia D. Tetany related to hypercalcemia

C. Tetany related to hypocalcemia

Tenderness/pain in the abdomen, dehydration, poor self-management

DKA

Left upper quadrant pain, NPO status, autodigestion

Pancreatitis