Exam 4

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:

separates into concentric rings and test positive of glucose

The nurse is admitting a client from the emergency department for a fall that resulted in increased intracranial pressure (ICP). The nurse interprets that the clients Glasgow Coma Scale score has improved most after making which of the following latest assessments?

-best eye opening 4 -best motor 6 -best verbal 5

The nurse is caring for a pt. who had a liver biopsy approx. 15 min ago. The patient is supine in bed, the nurse notes the pt's skin is pale and cool, and the pt. reports feeling lightheaded. The nurse's immediate response is to do which of the following?

-place pt. on right side -obtain vitals

After a bioterrorist attack, a patient presents with fever, weakness, pneumonia with SOB, and bloody sputum. What kind of precautions should this patient be placed under and what type of plague is suspected?

-pneumonic plague -contact precautions until decontamination

tympani percussion signs of pneumothoraxes

-simple pneumothorax will have hyperresonance and tympani -hemothorax will have dullness on percussion

A client arrives in the emergency department with an ischemic stroke. Before the client receives tissue plasminogen activator (t-PA) administration, which is the priority nursing assessment?

time of onset of current stroke

After a bioterrorist attack, a patient presents with swollen lymph nodes, a fever, chills, and a headache. What type of plague might this patient have?

Bubonic **remember bub sounds like bubbles and your lymph nodes look like swollen bubbles

A trauma pt. is suddenly exhibiting tachycardia, dilated neck veins, muffled heart tones and persistent hypotension despite receiving two liters of normal saline. What condition needs to be differentiated to intervene appropriately?

Cardiac tamponade

T or F? Hep A does not require contact precautions

False

T or F? Hep C is a rare indication for a liver transplant

False hep C is a big indication for liver transplant

Because ascitic fluids are rich in serum proteins, the client during or following a paracentesis is at greatest risk of experiencing:

Hypotension Why? B/c fluid is going back to the peritoneum --> reduced circulating volume

What is the purpose of the chest tube and how does the nurse evaluate its effectiveness?

It removes fluid and air; nurse monitors

The nurse should interpret which of the following as an early sign of tension pneuomothorax?

Respiratory distress

College freshmen are in a study abroad program. What teaching about Hep C should the nurse instruct students about?

Safe sex practice

Which of the following respiratory patterns indicates ICP in the stem?

Slow and irregular

A nurse develops a teaching plan for prevention of Hep A. Which discharge instructions are appropriate regarding Hep A?

Tell family to wash hands frequently

T or F? Hepatitis B and C can develop chronic carrier states after acute phase

True

T or F? You would instruct your patient that hep A and hp B can be prevented with a vax

True

A client is at increased risk for intracranial pressure. What is the priority for the nurse to monitor?

Unequal pupil size

An unconscious client with multiple injuries arrives to the ED. What is the highest nursing priority?

airway

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

an oral anticoagulant **remember ischemic attacks are caused by a clot

A patient presents to the ED with a painless ulcer with a black center. What does the nurse suspect the patient has been exposed to?

anthrax

Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be LEAST helpful to the client?

completing sentences that the client cannot finish **you WANT to: speak slowly, give client time to respond, look directly at client during attempts at speech

The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:

consistently uses adaptive equipment in dressing self

The signs and symptoms of tension pneumothorax include respiratory distress, absent breath sounds on the affected side, dsitended neck veins and...

decreased BP and tachy

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:

desmopressin

A client 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 skull and dura mater. Which type of head injury does this finding suggest?

epidural hematoma

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with:

epidural hematoma

The nurse planning care for client who suffered a cerebrovascular accident (CVA) with residual dysphagia would write on the care plan to AVOID doing which of the following during meals?

give the client thin liquids

A client with cirrhosis begins to develop ascites and spironolactone is prescribed. The nurse should monitor the patient for which potential side effect of spironolactone?

hyperkalemia **remember that SPironolactone is K+ SParing

A nurse monitoring a client who has sustained a head injury determines that the intracranial pressure (ICP) is rising if which of the following vital signs trends as noted during the work shift?

increased temp decreased pulse (bradycardia) decreased respirations increased BP (hypertension)

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

intracranial pressure is increased

What is a sign of hepatic encephalopathy?

mental status changes

A client who experienced a thrombotic stroke and has residual hemiparesis of the right side is undergoing rehabilitation. The nurse caring for this plant reinforces occupational therapy recommendations by placing items for personal hygiene:

on the over bed table on the left side

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

rapid dilantin administration can cause cardiac arrhythmias

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform FIRST?

reposition client to avoid neck flexion

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present?

rigid extension and pronation of arms and legs **remember decerebrate is worse

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

schedule a STAT CT scan of the head