Test 4
An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidentally burned in the new home? Cook for her. Stop her from smoking. Install tap water anti-scald devices. Be sure she uses an open space heater.
Install tap water anti-scald devices.
Le Fort III
transverse facial fractures begin at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit, through the nasolacrimal groove and ethmoid air cells
A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for: A. return of reflexes. B. bradycardia with hypoxemia. C. effects of sensory deprivation. D. fluctuations in body temperature.
B. bradycardia with hypoxemia. (neurogenic shock)
A young adult is hospitalized after an accident that resulted in complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to: A. breathe with respiratory support B. drive a vehicle with hand controls C. ambulate with long-leg braces and crutches D. use a powered device to handle eating utensils
B. drive a vehicle with hand controls
A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate? Elevate the right arm on two pillows for 24 hours. Apply heating pad to reduce muscle spasms and pain. Limit movement of the thumb and fingers on the right hand. Place arm in a sling to prevent movement of the right shoulder.
Elevate the right arm on two pillows for 24 hours.
A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? Prevent urinary tract infection. Monitor the patient every 15 minutes. Encourage him to verbalize his feelings. Teach him about using the gastrocolic reflex.
Encourage him to verbalize his feelings. (coping and prevent self harm)
When computing a heart rate from the electrocardiography (ECG) tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. What does the nurse calculate the patient's heart rate to be? 60 beats/min 75 beats/min 100 beats/min 150 beats/min
100 beats/min Because each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).
The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN? Assess skin integrity around the traction boot. Determine correct body alignment to enhance traction. Remove weights from traction when turning the patient. Monitor pain intensity and administer prescribed analgesics.
Monitor pain intensity and administer prescribed analgesics.
The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? Pain assessment Glasgow Coma Scale Respiratory assessment Musculoskeletal assessment
Respiratory assessment
This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? "No one is available to assist and accompany the patient." "The cast is not dry yet, and it may be damaged while using crutches." "Rest, ice, compression, and elevation are in process to decrease pain." "Excess edema and complications are prevented when the leg is elevated for 24 hours."
"Excess edema and complications are prevented when the leg is elevated for 24 hours."
The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD). Which statement by the patient indicates to the nurse that further teaching is needed? "The device may set off the metal detectors in an airport." "My family needs to keep up to date on how to perform CPR." "I should not stand next to antitheft devices at the exit of stores." "I can expect redness and swelling of the incision site for a few days."
"I can expect redness and swelling of the incision site for a few days."
A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? "I probably won't be able to play soccer for 6 to 8 months." "They will have me do range of motion with my knee soon after surgery." "I can't wait to get this done now so I can play soccer for the next tournament." "I will need to wear an immobilizer and progressively bear weight on my knee."
"I can't wait to get this done now so I can play soccer for the next tournament."
The nurse is doing discharge teaching with the patient who received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that further teaching is required? "I will call the cardiologist if my ICD fires." "I cannot fly because it will damage the ICD." "I cannot move my left arm until it is approved." "I cannot drive until my cardiologist says it is okay."
"I cannot fly because it will damage the ICD."
The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful? "I will perform self-catheterization at least six times per day." "A reflex erection may cause an unsafe drop in blood pressure." "If I develop a severe headache, I will lie down for 15 to 20 minutes." "I can avoid this problem by taking medications to prevent leg spasms."
"I will perform self-catheterization at least six times per day."
A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful? "Leg-raising exercises are necessary for several months." "I should not try to drive a motor vehicle for 2 to 3 weeks." "I will not have any restrictions now on hip and leg movements." "Blood tests will be done weekly while taking enoxaparin (Lovenox)."
"Leg-raising exercises are necessary for several months."
A patient develops third-degree heart block and reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? "The device will convert your heart rate and rhythm back to normal." "The device uses overdrive pacing to slow the heart to a normal rate." "The device is inserted through a large vein and threaded into your heart." "The device delivers a current through your skin that can be uncomfortable."
"The device delivers a current through your skin that can be uncomfortable."
A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%
22.5%
The nurse is monitoring the electrocardiograms of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action? A 62-yr-old man with a fever and sinus tachycardia with a rate of 110 beats/min A 72-yr-old woman with atrial fibrillation with 60 to 80 QRS complexes per minute A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute A 42-yr-old woman with first-degree AV block and sinus bradycardia at a rate of 56 beats/min
A 52-yr-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute
Which patient should the nurse prepare to transfer to a regional burn center? A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% A 39-yr-old patient with a partial-thickness burn to the right upper arm A 53-yr-old patient with a chemical burn to the anterior chest and neck A 42-yr-old patient who is scheduled for skin grafting of a burn wound
A 53-yr-old patient with a chemical burn to the anterior chest and neck
During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should: A. examine the mouth and teeth thoroughly B. have the patient clench and relax the jaw and eyes C. identify trigger zones by lightly touching the affected side D. gently palpate the face to compare skin temperature bilaterally
A. examine the mouth and teeth thoroughly
The nurse has just received a change-of-shift report for the burn unit. Which client should be assessed first? A. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain B. Client who just arrived from the emergency department with facial burns sustained in a house fire C. Client who has just been transferred from the post anesthesia care unit after having skin grafts applied to the anterior chest D. Client admitted 3 weeks ago with full thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching
B. Client who just arrived from the emergency department with facial burns sustained in a house fire
The nurse observes no P waves on the patients monitor strip. There are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. What does the nurse determine the rhythm to be? Sinus tachycardia Atrial fibrillation Ventricular fibrillation Ventricular tachycardia
Atrial fibrillation
When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)? The exercises are the only way to prevent contractures. Active and passive ROM maintain function of body parts. ROM will show the patient that movement is still possible. Movement facilitates mobilization of leaked exudates back into the vascular bed. Active and passive ROM can only be done while the dressings are being changed.
Active and passive ROM maintain function of body parts. ROM will show the patient that movement is still possible.
A patient reports dizziness and shortness of breath and is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole? Digoxin Adenosine Metoprolol Atropine sulfate
Adenosine
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? Administer 100% humidified oxygen. Teach the patient deep breathing exercises. Encourage the patient to express his feelings. Assist the patient to a high Fowler's position.
Administer 100% humidified oxygen.
When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)? Apply ice directly to the skin. Apply heat to the ankle every 2 hours. Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Perform passive and active range of motion.
Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart.
When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is: A. teach facial and jaw relaxation techniques B. assess intake and output and dietary intake C. apply ice packs for no more than 20 minutes D. spend time at the bedside talking with the patient
B. assess intake and output and dietary intake
A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? Test the drainage for the presence of glucose. Apply a loose gauze pad under the patient's nose. Place the patient in a modified Trendelenburg position. Ask the patient to gently blow the nose to clear the drainage
Apply a loose gauze pad under the patient's nose.
The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? Arteriogram showing blood vessels Peripheral pulse palpation bilaterally Patches of black, indurated, cold tissue Bilateral pale, cool skin below the ankles
Arteriogram showing blood vessels
A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? Insert a rectal stimulant suppository. Teach the patient to gradually increase intake of high-fiber foods. Assess bowel movements for frequency, consistency, and volume. Instruct the patient to avoid all caffeinated and carbonated beverages.
Assess bowel movements for frequency, consistency, and volume.
The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time? Reinforcing the pressure dressing as needed Encouraging range-of-motion exercises of the involved arm Assessing the incision for any redness, swelling, or discharge Applying wet-to-dry dressings every 4 hours to the insertion site
Assessing the incision for any redness, swelling, or discharge
A patient with Guillain-Barre syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barre syndrome: A. results from an acute infection and inflammation of the peripheral nerves B. is due to an immune reaction that attacks the covering of the peripheral nerves C. is caused by destruction of the peripheral nerves after exposure to a viral infection D. results from degeneration of the peripheral nerve caused by viral attacks
B. is due to an immune reaction that attacks the covering of the peripheral nerves
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses
Bradycardia
During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? A. a heart rate of 92 B. a reddened area over the patient's coccyx C. marked perspiration on the patient's face and arms D. a light inspiratory wheeze on auscultation of the lungs
C. marked perspiration on the patient's face and arms (autonomic dysreflexia)
A 24-year-old patient is hospitalized with the onset of Guillain-Barre syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is: A. monitoring the cardiac rhythm continuously B. determining the LOC a2h C. evaluating sensation and strength of the extremities D. performing constant evaluation of respiratory function
D. performing constant evaluation of respiratory function
The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? Recent knee trauma Debilitating joint pain Repeated knee infections Onset of frozen knee joint
Debilitating joint pain
In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? Serum sodium and potassium increase. Serum sodium and potassium decrease. Edema and arterial blood gases improve. Diuresis occurs and hematocrit decreases.
Diuresis occurs and hematocrit decreases.
A 68-yr-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation (select all that apply.)? Drink more milk. Eat 20-30 g of fiber per day. Use oral laxatives every day. Limit caffeinated beverages. Drink 1800 to 2800 mL of water or juice. Establish bowel evacuation time at bedtime
Eat 20-30 g of fiber per day. Limit caffeinated beverages. Drink 1800 to 2800 mL of water or juice.
Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? Urinary catheterization Check for bowel impaction Elevate the head of the bed Administer intravenous hydralazine
Elevate the head of the bed (to lower BP)
The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate? Promote vitamin C and calcium intake in the diet. Provide passive range of motion to all of the joints q4hr. Keep the left leg in extension and abduction to prevent contractures. Encourage isometric quadriceps-setting exercises at least four times a day.
Encourage isometric quadriceps-setting exercises at least four times a day.
The nurse observes a flat line on the patient's monitor and the patient is unresponsive without pulse. What medications does the nurse prepare to administer? Lidocaine and amiodarone Digoxin and procainamide Epinephrine and/or vasopressin β-adrenergic blockers and dopamine
Epinephrine and/or vasopressin
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care (select all that apply.)? Escharotomy Administration of diuretics IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent
Escharotomy IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent
The patient has a potassium level of 2.9 mEq/L, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm, the P wave is 0.06 seconds (sec) and normal shape, the PR interval is 0.24 sec, and the QRS is 0.09 sec. How should the nurse document this rhythm? First-degree AV block Second-degree AV block Premature atrial contraction (PAC) Premature ventricular contraction (PVC)
First-degree AV block
Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? Headache and rising blood pressure Irregular respirations and shortness of breath Decreased level of consciousness or hallucinations Abdominal distention and absence of bowel sounds
Headache and rising blood pressure
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods
High-calorie and high-protein foods
The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? Administer enoxaparin (Lovenox). Provide range-of-motion exercises. Apply sequential compression boots. Immobilize the fracture preoperatively.
Immobilize the fracture preoperatively.
When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? Impaired urinary elimination related to tetraplegia Risk for impaired tissue integrity related to paralysis Disabled family coping related to the extent of trauma Ineffective airway clearance related to cervical spinal cord injury
Ineffective airway clearance related to cervical spinal cord injury
The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? Subcutaneous (SQ) tetanus toxoid Intravenous (IV) morphine sulfate Intramuscular (IM) hydromorphone Oral oxycodone and acetaminophen
Intravenous (IV) morphine sulfate
The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? Keep a wrench close or attached to the vest. Use the frame and vest to assist in positioning. Clean around the pins using betadine swab sticks. Loosen both sides of the vest to provide skin care.
Keep a wrench close or attached to the vest.
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 g IV Urine for myoglobulin Lactated Ringer's solution at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours
Lactated Ringer's solution at 25 mL/hr
The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? Pain Left knee stiffness Left knee infection Left knee instability
Left knee infection
The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? 2 × 6 cm right calf abrasion with sanguineous drainage Left leg externally rotated and shorter than the right leg Stooped posture with a shuffling gait and slow movements Mild pain and minimal swelling of the right ankle and foot
Left leg externally rotated and shorter than the right leg (hip fracture)
A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care? Sit in a chair for 1 to 2 hours three times each day. Dangle the residual limb for 20 to 30 minutes every 6 hours. Lie prone with hip extended for 30 minutes four times per day. Elevate the residual limb on a pillow for 4 to 5 days after surgery.
Lie prone with hip extended for 30 minutes four times per day.
A patient with type 2 diabetes mellitus is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? Replace the blood lost. Maintain a neutral pH. Maintain fluid balance. Replace serum potassium
Maintain fluid balance.
The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? Uses an elevated toilet seat Sits with feet flat on the floor Maintains hip in adduction and internal rotation Verifies need to notify future caregivers about the prosthesis
Maintains hip in adduction and internal rotation
The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery.
Monitor for signs of complications.
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? Morphine Sertraline Zolpidem Enoxaparin
Morphine
Comminuted skull fracture
Multiple linear fracture (2+) with fragmentation of the bone into many pieces cause: direct, high-momentum impact
The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? Myocardia injury Myocardial ischemia Myocardial infarction A pacemaker is present.
Myocardial ischemia
A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure
No pain, waxy white skin, and no blanching with pressure
A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? Notify the health care provider immediately. Elevate the left leg above the level of the heart. Administer prescribed morphine sulfate intravenously. Apply ice packs to the left proximal tibia over the cast.
Notify the health care provider immediately. (compartment syndrome)
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
A patient informs the nurse of experiencing syncope. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? Preparing to assist with a head-up tilt-test Preparing an IV dose of a β-adrenergic blocker Assessing the patient's knowledge of pacemakers Teaching the patient about the role of antiplatelet aggregators
Preparing to assist with a head-up tilt-test
The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? Progressive leg exercises to obtain 90-degree flexion Early ambulation with full weight bearing on the left leg Bed rest for 3 days with the left leg immobilized in extension Immobilization of the left knee in 30-degree flexion to prevent dislocation
Progressive leg exercises to obtain 90-degree flexion
The nurse observes ventricular tachycardia (VT) on the patient's monitor. What evaluation made by the nurse led to this interpretation? Unmeasurable rate and rhythm Rate 150 beats/min; inverted P wave Rate 200 beats/min; P wave not visible Rate 125 beats/min; normal QRS complex
Rate 200 beats/min; P wave not visible
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands
Reddening of the skin
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? Sit or lie in the position of comfort. Wear a pressure garment for 8 hours each day. Refer the patient to a counselor for psychosocial support. Use the sun to increase the skin color on the healed areas.
Refer the patient to a counselor for psychosocial support.
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)? Singed nasal hair Generalized pallor Painful swallowing Burns on the upper extremities History of being involved in a large fire
Singed nasal hair Generalized pallor Painful swallowing History of being involved in a large fire
The nurse has obtained this rhythm strip from her patient's monitor. What should the nurse document this rhythm indicates? The rate on this strip is above 101 beats/min, and it displays normal P wave, PR interval, and QRS complex. Sinus tachycardia Sinus bradycardia Ventricular fibrillation Ventricular tachycardia
Sinus tachycardia
The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters. Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.
Skin is shiny and red with clear, fluid-filled blisters.
The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? Central cord syndrome Spinal shock syndrome Anterior cord syndrome Brown-Séquard syndrome
Spinal shock syndrome
The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment option does the nurse prepare the patient for? Defibrillation Synchronized cardioversion Automatic external defibrillator (AED) Implantable cardioverter-defibrillator (ICD)
Synchronized cardioversion
A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? Tachycardia Restlessness Hypokalemia Gastrointestinal (GI) distress
Tachycardia
Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the electrocardiogram (ECG)? The length of time it takes to depolarize the atrium The length of time it takes for the atria to depolarize and repolarize The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers The length of time it takes for the electrical impulse to travel from the sinoatrial (SA) node to the atrioventricular (AV) node
The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers
The nurse obtains a 6-second rhythm strip and charts the following analysis: Atrial data: Rate: 70, regular; variable PR interval Independent beats Ventricular data: Rate: 40, regularIsolated escape beats Additional data: QRS: 0.04 secP wave and QRS complexes unrelated Sinus dysrhythmia Third-degree heart block Wenckebach phenomenon Premature ventricular contractions
Third-degree heart block
The nurse determines there is artifact on the patient's telemetry monitor. Which factor should the nurse assess for that could correct this issue? Disabled automaticity Electrodes in the wrong lead Too much hair under the electrodes Stimulation of the vagus nerve fibers
Too much hair under the electrodes
Cardioversion is attempted for a patient with atrial flutter and a rapid ventricular response. After the delivering 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? Administer 250 mL of 0.9% saline solution IV by rapid bolus. Assess the apical pulse, blood pressure, and bilateral neck vein distention. Turn the synchronizer switch to the "off" position and recharge the device. Tell the patient to report any chest pain or discomfort and administer morphine sulfate.
Turn the synchronizer switch to the "off" position and recharge the device.
The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)? Urine output is 46 mL/hr. Heart rate is 94 beats/min. Urine specific gravity is 1.040. Mean arterial pressure is 54 mm Hg. Systolic blood pressure is 88 mm Hg.
Urine output is 46 mL/hr. Heart rate is 94 beats/min.
An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? Use mirror therapy. Give opioid analgesics. Rebandage the residual limb. Show the patient the leg is gone.
Use mirror therapy.
The nurse prepares to defibrillate a patient. For which dysrhythmia has the nurse observed in this patient? Ventricular fibrillation Third-degree AV block Uncontrolled atrial fibrillation Ventricular tachycardia with a pulse
Ventricular fibrillation Defibrillation is always indicated in the treatment of ventricular fibrillation.
A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the physician
d. Anticipate the need for endotracheal intubation and notify the physician
Caring for a child with a basilar skull fracture, the nurse understands that the child is at risk for developing meningitis because:
of the proximity to the sinuses and nasal pharynx which may contaminate the cerebral spinal fluid
Le Fort II
pyramidal fracture, extends from the nasal bridge at or below the nasofrontal suture through the superior medial wall of the maxilla
The nurse is assigned care for an 8 y/o child with a diagnosis of a basilar skull fracture; the nurse reviews the HCPs orders and should question the order about:
suction as needed (increases ICP)
Diastatic skull fracture
fracture that separates the cranial sutures in children prior to close of fissures (< 3 years old)
Le Fort I
horizontal, floating palate, fracture of the maxillary alveolar ridge, upper dental row and inferior nasal septum
Depressed skull fracture
inward indentation of skull; sunken in cause: powerful blow requires surgical intervention to fix the deformity
A client was re-admitted to the hospital following a recent skull fracture. Which finding requires a nurse's immediate attention?
lethargy (altered LOC)
Linear skull fracture
most common type break in the continuity of bone without alteration of relationship of parts cause: low-velocity injuries observed in hospital and then discharged
Basilar skull fracture
most serious; break in the bone at the base of the skull diffuse impact to the head may require surgery signs: Raccoon eyes (periorbital ecchymosis), Battle's sign (postauricular ecchymosis), otorrhea, CSF drainage, hemotypanum *usually started on antibiotics to prevent meningitis
