Test 5 - MEDSURG 3

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Anatomy of the Brain

Falls

The most common cause of traumatic brain injury is______.

Surgical resection Surgical resection is the preferred method of treating clients with localized non-small cell tumors, with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.

The nurse is caring for an adult client recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating clients with non-small cell tumors is what?

Describes an injury that is the result of an external force and is of sufficient magnitude to interfere w/daily life and prompts the seeking of treatment

Traumatic Brain Injury (TBI)

Call the health care provider immediately A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

To remove atherosclerotic plaques blocking cerebral flow The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

Preparing to assist with intubating the client A client who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.

A client has been brought to the ED by the paramedics. The client is suspected of having acute respiratory distress syndrome (ARDS). What intervention should the nurse first anticipate?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the client's health status." Treatment of lung cancer depends on the cell type, the stage of the disease, and the client's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the client's age or the client's preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the client and the physician of which treatment is best, though this discussion will take place.

A client has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the client asks the nurse how the treatment is decided upon. What would be the nurse's best response?

To remove air from the pleural space Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

Express empathy and then encourage the client to write, use a picture board, or spell words with an alphabet board. If the client uses an alternative method of communication, he will feel in better control and likely be less frustrated. Assuring the client that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. In a client with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the client's wishes. Making them responsible for interpreting the client's gestures may frustrate the family. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

A client recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the client?

Cardiac and respiratory status Acute care begins with managing ABCs. Clients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus?

Administration of treatments Assistance with self-care Pain control Management of treatment complications Home care needs and interventions focus on four major areas: palliation of symptoms and pain control, assistance in self-care, control of treatment complications, and administration of specific forms of treatment, such as parenteral nutrition. Interpretation of diagnostic tests is normally beyond the purview of the nurse.

A client with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply.

Maintain and improve cerebral tissue perfusion Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized?

Suction the client's airway secretions. As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.

An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care?

A resident who suffered a stroke several weeks ago Aspiration may occur if the client cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A client with mid-stage Alzheimer disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have arthritis should not have difficulty swallowing unless it exists secondary to another problem.

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?

.The cough reflex is depressed. There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the client's cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.

The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?

Brain natriuretic peptide (BNP) level Common diagnostic tests performed for clients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology?

Alteration in level of consciousness (LOC) Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Diminished or absent breath sounds on the affected side In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax?

Depression Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in their life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image?

Early ambulation For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?

A client requires permanent ventilation. A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed client. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy?

Elevation of the head of the bed Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal?