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A patient has been admitted with a stroke. The nurse anticipates a practitioner's order for which diagnostic study before initiating therapy? a. Magnetic resonance imaging b. Noncontrast computed tomography c. Lumbar puncture d. Contrast computed tomography
b. Noncontrast computed tomography
A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with the syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include? a. Fluid restriction b. Administration of 3% normal saline c. Administration of exogenous vasopressin d. Low sodium diet
a. Fluid restriction
. The nurse educates a patient following a transient ischemic attack (TIA). The nurse recognizes further education is needed following which patient statement? a. "I understand TIAs may result in permanent damage to my brain tissue." b. "I now have a high risk of stroke since I have had a transient ischemic attack." c. "I need to alert my healthcare provider about any symptoms that last longer than an hour." d. "I need to manage my high blood pressure to reduce my risk of stroke."
a. "I understand TIAs may result in permanent damage to my brain tissue."
During a change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?
a. 4 b. 2 c. 3 d. 1
After a change of shift report, which patient should the nurse assess first? a. A 23 yr old patient with type 1 diabetes who has a blood glucose of 30mg/dL b. A 43-year-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL c. A 19-year-old patient with type 1 diabetes who has a hemoglobin A1C of 12% d. A 50-year-old patient uses exenatide (Byetta) and is complaining of acute abdominal pain
a. A 23 yr old patient with type 1 diabetes who has a blood glucose of 30mg/dL anything >70 is BAD!
A nurse is caring for a patient in the emergency department. The nurse observes the monitor and notes the rhythm (image attached). The patient has a blood pressure (BP) of 80/42 mmHg and reports dyspnea, chest pain, and feeling faint. Which actions should the nurse prepare to take? (Select all that apply). (PICTURE is SVT) a. Administer adenosine 6mg intravenously. b. Intrust the patient to Valsalva c. Initiate cardiopulmonary resuscitation and chest compressions. d. Rapid defibrillation. e. Ensure patent peripheral IV access
a. Administer adenosine 6mg intravenously. b. Intrust the patient to Valsalva e. Ensure patent peripheral IV access
A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which actions should the nurse take first? a. Assess the blood pressure (BP) b. Notify the health care provider c. Give the prescribed antiemetic d. Check for fecal impaction
a. Assess the blood pressure (BP)
A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic? DAP → a. Collection of blood between the dura mater and the skull → pg. 1314 b. Bleeding directly in the brain parenchyma → (Intracerebral Hematoma) c. Collection of blood between the arachnoid membrane and the pia mater → (Subarachnoid) d. Collection of the blood between the dura mater and the arachnoid membrane → (Subdural)
a. Collection of blood between the dura mater and the skull → pg. 1314
A nurse is caring for a patient who has a spinal cord injury. To prevent autonomic dysreflexia in this patient, the nurse should take measures for the patient to avoid? a. Developing urinary retentions b. Person with upper respiratory infections c. Emotional stress d. Smoking cigarettes
a. Developing urinary retentions
The nurse is caring for a client with fluid overload. The nurse assesses dor which of the clinical manifestations of fluid overload? (Select all that apply). a. Increased central venous pressure b. Edema to bilateral ankles c. Decreased blood pressure d. Crackles upon auscultation e. Weight loss of five pounds overnight
a. Increased central venous pressure b. Edema to bilateral ankles d. Crackles upon auscultation
The nurse cares for a patient with severe traumatic brain injury on mechanical ventilation. The nurse implements which interventions? (SATA) a. Keep the head of the bed elevated as prescribed b. Cluster nursing care activates during each shift c. Maintain a quiet room with dimmed lights - Quizlet d. Encourage family members to visit in groups e. Suction airway secretion only as needed
a. Keep the head of the bed elevated as prescribed c. Maintain a quiet room with dimmed lights e. Suction airway secretion only as needed
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following is an expected finding? a. Kussmaul Respiration b. Urine negative for ketones c. Distended neck veins d. Elevated blood pressure
a. Kussmaul Respiration
A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Detemir (Levemir) c. NPH (Humulin N) d. Glargine (Lantus)
a. Lispro (Humalog)
The nurse is caring for a 46-year-old male patient who sustained head trauma with increased intracranial pressure and is currently being mechanically ventilated. The patient management plan should include which intervention? a. Maintain the PaCO2 between 35 and 45 mm Hg. b. Maintain the respiratory rate of 20 breaths/min c. Maintain the PaCO2 between 45 and 50 mmHg d. Maintain the FiO2 at 80%
a. Maintain the PaCO2 between 35 and 45 mm Hg. ( too little Vasodilate, & too much Vasocontrict)
8. A nurse monitors a patient who has a stroke 36 hours ago of increased intracranial pressure (ICP). Which finding related to ICP does the nurse report to the healthcare provider? (SATA) a. Pinpoint and nonreactive pupils b. Decerebrate posturing c. Severe hypotension d. Declining level of consciousness e. Patient report of a headache
a. Pinpoint and nonreactive pupils b. Decerebrate posturing d. Declining level of consciousness e. Patient report of a headache
The nurse has admitted a patient with a hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient? a. Severe hyperglycemia with minimal or absent ketosis b. Little or no ketosis in serum with rapidly escalating ketonuria c. Hyperglycemia and ketosis d. Hyperglycemia with low serum osmolarity
a. Severe hyperglycemia with minimal or absent ketosis
6. A nurse assesses a patient for a potential cerebrovascular accident (CVA). For which signs does the nurse assess? (SATA) a. Sudden severe headache b. Dull aching pain in the jaw c. Inability to move an extremity d. Ptosis of the eyelid (p. LEWIS 1304) e. Difficulty understanding speech
a. Sudden severe headache c. Inability to move an extremity d. Ptosis of the eyelid (p. LEWIS 1304) e. Difficulty understanding speech
The nurse cares for a client with the syndrome of inappropriate antidiuretic hormone (SIADH), which assessment findings are likely to be identified in this client? (SATA) - pg. 1147 a. The client has full bounding pulse b. The client has hypoactive bowel sounds c. The client has increased urine osmolarity d. The client displays dependent edema e. The client has a decreased serum sodium
a. The client has full bounding pulse (ATI p.522 c. The client has increased urine osmolarity e. The client has a decreased serum sodium (ATI 522)
A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate reports a history of Type I diabetes. The patient used the last diabetes testing supplies 3 days ago. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply). a. pH 7.23 b. HCO3 10 mEq/L c. Blood glucose 524 mg/dL d. Blood glucose 43 mg/dL e. PaC02 37 mm Hg
a. pH 7.23 b. HCO3 10 mEq/L c. Blood glucose 524 mg/dL
A patient receives Aspart (Novolog) at 0800. Breakfast is served at 0815. What time should the nurse expect the Novolog to peak? (Peak: 30 mins to 3 hours) pg. 1114 a. 1400 b. 1000 c. 1200 d. 0815
b. 1000
A nurse taking care of a patient that is suspected of having diabetes insipidus knows that the primary health care physician will order what diagnostic test? a. A CT scan of the abdomen and pelvis b. A water deprivation test c. X-ray of the chest d. A fasting glucose test
b. A water deprivation test
Which cranial nerves are responsible for motor functions of the eye? (Select all that apply) a. Accessory (X) b. Abducens (VI) c. Trochlear (IV) d. Optic nerve (II) e. Oculomotor (III)
b. Abducens (VI) c. Trochlear (IV) e. Oculomotor (III)
A nurse is caring for a patient in the ICU. The nurse observes the monitor and notes the rhythm (image attached its sinus brady). The patient has a blood pressure (BP) of 80/42 mm Hg and reportsfeeling faint. Which action should the nurse take? a. Give the scheduled dose of diltiazem (Cardizem) b. Apply the transcutaneous pacemaker (TCP) pads. c. Have the patient perform the Valsalva maneuver d. Reposition the patient on the left side
b. Apply the transcutaneous pacemaker (TCP) pads.
. A patient in the clinic reports a recent episode of dysphasia and left sided weakness at home that resolves after 20 minutes. The nurse will anticipate teaching the patient about? a. Alteplase (tPA) b. Aspirin (Ecotrin) c. Nimodipine d. Warfarin (Coumadin)
b. Aspirin (Ecotrin)
Which laboratory results would indicate that the patient has prediabetes? a. Glucose tolerance result of 240 mg/dL b. Fasting blood glucose result of 120 mg/dL c. Glucose tolerance result of 132 mg/dL d. Fasting blood glucose result of 80 mg/dL
b. Fasting blood glucose result of 120 mg/dL (100 to 125 mg/dL)
9. The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which electrolyte abnormality does the nurse anticipate finding? a. Hyperkalemia b. Hyponatremia c. Hypocalcemia d. Hypernatremia
b. Hyponatremia
In a patient with central diabetes insipidus, what is the expected outcome of administering ADH during a water deprivation test? a. Decrease in blood pressure b. Increase in urine osmolality c. Decrease in body weight d. Increase in urinary output
b. Increase in urine osmolality - pg. 1148
. A patient's endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient's lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that a. The stethoscope earpiece is clogged with wax b. The endotracheal tube is in the right mainstem bronchus c. The patient has a left pneumothorax d. The patient has aspirated secretions during the procedure
b. The endotracheal tube is in the right mainstem bronchus
The nurse educates a patient admitted with hyperglycemic hyperosmolar state (HHS). The nurse provides information about preventing another episode of HHS acute illness. Which patient statement demonstrates further education is needed? a. "I will continue to take my diabetes medication when I'm sick." b. "I will monitor my blood glucose levels at least every four hours." c. "I will check for ketones if my blood sugar is above 300 mg/dL." d. "I will drink at least eight ounces of fluid every hour when I'm sick."
c. "I will check for ketones if my blood sugar is above 300 mg/dL."
After the emergency department nurse has received a status report of the following patients with head injuries, which patient should the nurse assess first? a. A 43-year-old patient who has an initial Glasgow Scale score of 13 b. A 30-year-old patient who lost consciousness for 10 second after a fall c. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light d. A 20-year-old patient whose cranial x-ray shows a linear skull fracture
c. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
Which statement best reflects the overall physiologic effects of Antidiuretic Hormone (ADH)? a. Increase sodium excretion and therefore promotes diuresis b. Causes the kidneys to excrete more water c. Causes the kidney to absorb water d. Controls the vasomotor response of the renal vasculature affecting urine output
c. Causes the kidney to absorb water
The nurse is reviewing discharge instructions with a patient who is 4 days post-heart valve surgery when the bedside ECG monitor alarms loudly and displays the following sustained ECG rhythm. Which intervention should the nurse implement first? (PICTURE is polymorphic vtach) a. Obtain a 12 lead ECG b. Prepare to defibrillate the patient c. Check for a pulse d. Administer lidocaine, an antidysrhythmic, IVP
c. Check for a pulse → To check if its V-Tach w/ pulse or w/ pulselessness
What is the large opening at the base of the cranium called? a. Median foramen b. Cisterna magna c. Foramen magnum d. Lateral foramen
c. Foramen magnum
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Oxygen saturation b. PT/aPTT/INR c. Intracranial pressure d. Hemoglobin and hematocrit
c. Intracranial pressure
Which AV block (image attached) can be described as a gradually lengthening PR interval until ultimately the final P wave in the group falls to conduct? a. First-degree AV block b. Third-degree AV block c. Second degree AV block, type I d. Second degree AV block, type II
c. Second degree AV block, type I
The nurse performs a neurological assessment on a client admitted with a traumatic brain injury. Which new finding does the nurse immediately report to the healthcare provider? a. The client scores 12 on the Glasgow coma scale b. Fasciculations are noted around the face and eyes c. The client demonstrates decerebrate posturing d. The client exhibits 3+ cutaneous reflexes
c. The client demonstrates decerebrate posturing
24. Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C4 spinal cord injury? a. Application of pneumatic compression devices to legs b. Administration of low-molecular-weight heparin c. Cardiac monitoring for bradycardia d. Assessment of respiratory rate and effort
d. Assessment of respiratory rate and effort
What medication would the nurse expect to be prescribed for the patient? A nurse is caring for a malignant brain tumor who has developed diabetes insipidus (DI). a. Propylthiouracil b. Glucagon c. Insulin d. Desmopressin
d. Desmopressin
Which pathophysiology mechanism occurs in the syndrome of inappropriate antidiuretic hormones (SIADH)? a. Hypermetabolism b. Hemoconcentration c. Massive diuresis d. Dilutional hyponatremia
d. Dilutional hyponatremia
Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a. Impaired nutrition more than body requirements b. Activity intolerance c. Hyperthermia d. Fluid volume deficit
d. Fluid volume deficit
What describes the primary difference in treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)? a. Administration of glucose is withheld in HHS until the blood glucose reaches a normal level. b. DKA requires administration of bicarbonate to correct acidosis c. Potassium replacement is not necessary for the management of HHS d. HHS requires greater fluid replacement to correct the dehydration (Ld. HHS requires greater fluid replacement to correct the dehydration
d. HHS requires greater fluid replacement to correct the dehydration (Lewis 1133)
The nurse cares for a client presenting with a suspected cervical spine fracture. The client is alert, oriented, and moving all extremities but reports head and neck pain. Which is the priority nursing intervention? a. Provide the client with pain medications as prescribed by the healthcare provider b. Assist the client into a hospital gown to prepare for cervical spine imaging c. Establish IV access for fluid and medication administration d. Immobilize the client's neck until cervical spine regarding imaging can be obtained
d. Immobilize the client's neck until cervical spine regarding imaging can be obtained
A patient has a tumor in the cerebellum. The nurse will plan interventions to: a. Improve memory b. Avoid aspiration c. Stabilize mood d. Prevent falls
d. Prevent falls
The nurse is caring for a patient with a diagnosis of malignant small cell carcinoma. The nurse notes that the patient's urine output has significantly decreased and gained 4 lbs over the last 24 hours. The nurse suspects that the patient may be developing? a. HHS (hyperosmolar hyperglycemic syndrome "No Ketones") dehydration b. DI (diabetes insipidus) dehydration c. DKA (diabetic ketoacidosis) dehydration d. SIADH (Syndrome of inappropriate antidiuretic hormone secretion)
d. SIADH (Syndrome of inappropriate antidiuretic hormone secretion)
Decreased urine osmolality is a sign of which disorder? a. Diabetes insipidus b. Hyperglycemia c. Thyroid crisis d. Syndrome of inappropriate secretion of antidiuretic hormone
d. Syndrome of inappropriate secretion of antidiuretic hormone
While caring for a client with traumatic brain injury (TBI), the nurse observed a yellow ring surrounding a clear, damp area on the client's pillow underneath the area of the ear. The nurse takes which action? a. The nurse assesses the client for symptoms of ear infection, including pain, difficulty hearing, and poor balance b. The nurse recognizes the ring as an experienced occurrence following TBI and documents this change c. The nurse recognizes the ring as an emergency and alerts the nursing supervisor and rapid response team d. The nurse suspects the ring is cerebrospinal fluid drainage that should be monitored and reported to the healthcare provider
d. The nurse suspects the ring is cerebrospinal fluid drainage that should be monitored and reported to the healthcare provider
When caring for a patient with nephrogenic diabetes insipidus, what should the nurse expect treatment to include? a. Fluid restriction b. A high sodium-diet c. Metformin (Glucoohagel) d. Thiazide diuretics
d. Thiazide diuretics
A patient is admitted with diabetes ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? e. Administer insulin and fluids intravenously f. Prepare for intubation g. Administer sodium bicarbonate h. Initiate oxygen therapy via a face mask
e. Administer insulin and fluids intravenously
27. A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEg/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) 1. Vasopressin 10 units IM every 3 hours 2. Insulin infusion at 5 units/h 3. Sodium bicarbonate 50 mmol IV push 4. NS 1.5 L IV fluid bolus 5. Potassium 29 mEq/L of IV fluid
pH less than < 7.0 give Sodium Bicarbonate - pg. 1132 Table 48.18 2. Insulin infusion at 5 units/h 4. NS 1.5 L IV fluid bolus 5. Potassium 29 mEq/L of IV fluid
