MedSurg II FINAL EXAM PrepU

A client has been diagnosed with heart failure. What is the major nursing outcome for the client? Sleep 8 hours per night. Walk 30 minutes three times a week. Reduce the workload on the heart. Maintain a healthy diet.

Reduce the workload on the heart. Specific objectives of medical management of heart failure include reducing the workload on the heart by reducing preload and afterload. The other choices are objectives that may be supportive of a healthy lifestyle, but are not specific to a client with heart failure.

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? Projectile vomiting Decreased pulse and respirations Disorientation and restlessness Loss of corneal reflex

Disorientation and restlessness Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

Which of the following eye disorders is caused by an elevated intraocular pressure (IOP)? Cataracts Hyperopia Myopia Glaucoma

Glaucoma In glaucoma, there is an abnormally high IOP. Cataracts occur when there is a clouding of the lens. Hyperopia is farsightedness. Myopia is nearsightedness.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? Epileptic cry Body rigidity Urinary incontinence Confusion

Confusion In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonicclonic contraction) during the seizure.

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? Every 15 minutes Every 45 minutes Every hour Every 30 minutes

Every 15 minutes Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.

Chemical burns of the eye are immediately treated by: Administering local anesthetics and antibacterial drops for 24 to 36 hours. Applying hot compresses at 15-minute intervals. Flushing the lids, conjunctiva, and cornea with tap water or normal saline. Cleansing the conjunctiva with a small cotton-tipped applicator.

Flushing the lids, conjunctiva, and cornea with tap water or normal saline. The immediate response is to always flush the affected eyelid and eye with normal saline or tap water to dilute the effectiveness of the agent that is causing the burn.

One of the most frequently occurring complications (55% occurrence) of primary hyperparathyroidism is: Kidney stones. Pancreatitis. Peptic ulcer. Pathologic fractures.

Kidney stones. Kidney stones occur in 55% of patients with primary hyperparathyroidism. They are caused by renal damage from the precipitation of calcium phosphate in the renal pelvis and parenchyma.

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client?

MS is a progressive demyelinating disease of the nervous system. MS is a chronic, degenerative, progressive disease of the central nervous system, characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known, and the disease affects twice as many women as men.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Water-seal chest drainage set-up Oxygen analyzer Tracheostomy cleaning kit Manual resuscitation bag

Manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting? Monitor and record radial pulses daily Monitor bowel movements Monitor and record blood pressure daily Monitor weight daily

Monitor weight daily To assess fluid balance at home, the client should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.

Which of the following is considered a central nervous system (CNS) disorder? Myasthenia gravis Guillain-Barré Multiple sclerosis Bell's palsy

Multiple sclerosis Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? Excessive urine output and serum hyponatremia Excessive urine output and decreased urine osmolality Oliguria and serum hyperosmolarity Oliguria and serum hyponatremia

Oliguria and serum hyponatremia SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute.

A nurse is caring for a 6-year-old client with cystic fibrosis.To enhance the child's nutritional status, which priority intervention should be included in the plan of care? Provision of five to six small meals per day rather than three larger meals Total parenteral nutrition (TPN) Magnesium, thiamine, and iron supplementation Pancreatic enzyme supplementation with meals

Pancreatic enzyme supplementation with meals Nearly 90% of clients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals. Frequent, small meals or TPN are not normally indicated. Vitamin supplements are required, but specific replacement of magnesium, thiamine, and iron is not typical.

A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess?

Pinpoint pupils Signs of an acute overdose of heroin, an opioid, include pinpoint pupils, marked respiratory depression, decreased blood pressure, stupor progressing to coma, seizures, and pulmonary edema. Flushed face typically reflects a barbiturate overdose.

A client presents to the ED in distress and reporting "crushing" chest pain. What is the nurse's priority for assessment? Auscultation of the client's point of maximal impulse (PMI) Prompt initiation of an ECG Palpation of the client's cardiac apex Rapid assessment of the client's peripheral pulses

Prompt initiation of an ECG The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a client reports pain or arrives in the ED. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Inspiratory crackles Cyanosis Bilateral wheezing Rapid onset of severe dyspnea

Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

When caring for a client with essential hypertension what instruction should the nurse provide to the client to normalize blood pressure? Increase iodine intake. Increase intake of fluids. Avoid intake of low-fat diet. Reduce sodium intake.

Reduce sodium intake. The nurse advises the client with essential hypertension to reduce sodium intake. The nurse also advises the client to reduce oral fluid to decrease circulating blood volume and systemic vascular resistance and adhere to a low-fat diet.

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?

Rheumatic fever Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.

A client reports headaches and "just not feeling right," which the client blames on ongoing sleep disturbances. Inspection reveals Janeway lesions on the bottoms of the client's feet. These symptoms may indicate: rheumatic fever. myocarditis. dilated cardiomyopathy. infective endocarditis.

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The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client? The client should not feel pain during initiation of dialysis. The client feels best immediately after the dialysis treatment. Taking a BP reading on the affected arm can damage the fistula. Using a stethoscope for auscultating the fistula is contraindicated.

Taking a BP reading on the affected arm can damage the fistula. When blood flow is reduced through the access for any reason (hypotension, application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, clients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, a needle stick is still painful.

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? Perfusion exceeds ventilation. Ventilation exceeds perfusion. There is an absence of perfusion and ventilation. Ventilation matches perfusion.

Ventilation exceeds perfusion. A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: Brudzinski's sign. a positive edrophonium (Tensilon) test. Kernig's sign. a positive sweat chloride test.

a positive edrophonium (Tensilon) test. A positive edrophonium test confirms the diagnosis of myasthenia gravis. After edrophonium administration, most clients with myasthenia gravis show markedly improved muscle tone. Kernig's sign and Brudzinski's sign indicate meningitis. The sweat chloride test is used to confirm cystic fibrosis.

The nurse witnesses a client experiencing ventricular fibrillation. What is the nurse's priority action? defibrillation cardioversion IV bolus of dobutamine IV bolus of atropine

defibrillation Advanced cardiac life support recommends early defibrillation for witnessed ventricular fibrillation. A cardioversion is used with a client who has a pulse. Atropine is used for bradycardia and dobutamine is an inotropic medication used to increased cardiac output.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: a recent driving accident while changing lanes. headaches, nausea, and redness of the eyes. light flashes and floaters in front of the eye. frequent episodes of double vision.

light flashes and floaters in front of the eye. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.

The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? pH 7.87, PaCO2 38, HCO3 28 pH 7.49, PaCO2 34, HCO3 25 pH 7.47, PaCO2 28, HCO3 30 pH 7.25, PaCO2 48, HCO3 24

pH 7.25, PaCO2 48, HCO3 24 pH less than 7.35, PaCO2 48, HCO3 24 indicate respiratory acidosis; pH 7.87, PaCO2 38, HCO3 28 indicate metabolic alkalosis; pH 7.47, PaCO2 28, HCO3 30 indicate respiratory alkalosis; and pH 7.49, PaCO2 34, HCO3 25 indicate respiratory alkalosis.

During a mass casualty incident (hurricane), a triage nurse participated in separating patients according to the severity of their injuries. She tagged a patient with a sucking chest wound with the color: black yellow green red

red Red refers to a life-threatening but survivable injury. Refer to Table 56-3 in the text for an explanation of the other colors.

Which would be least likely to contribute to a case of hospital-acquired pneumonia? A highly virulent organism is present. Host defenses are impaired. A nurse washes her hands before beginning client care. Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses.

A nurse washes her hands before beginning client care. HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

A nurse reviews an ECG strip for a client who is admitted with symptoms of an acute MI. The nurse should recognize what classic ECG changes that occur with an MI? Select all that apply. Abnormal Q-waves ST-segment elevations T-wave hyperactivity and inversions Absent P-waves U-wave elevations

Abnormal Q-waves T-wave hyperactivity and inversions ST-segment elevations These three signs are classic ECG changes suggestive of a myocardial infarction. Changes can be diagnostic to the area of cellular damage. P wave and U wave changes are not characteristic of an MI.

A client has been exposed to cyanide. Which of the following would the nurse expect to assist in administering? Select all that apply. Sodium thiosulfate Dimercaprol Sodium nitrite Atropine Amyl nitrate

Amyl nitrate Sodium nitrite Sodium thiosulfate Treatment of cyanide exposure involves the use of amyl nitrate, sodium nitrite, and sodium thiosulfate. Atropine is used to treat nerve agent poisoning. Dimercaprol is used to treat systemic toxicity of vesicants.

The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse? Fatigue Syncope An extra heart sound Dizziness

An extra heart sound Often the first and only sign of mitral valve prolapse is identified when a physical examination of the heart reveals an extra heart sound, referred to as a mitral click. Fatigue, dizziness, and syncope are other symptoms of mitral valve prolapse.

Which type of shock occurs from an antigen-antibody response? anaphylaxis

Anaphylactic During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure? Complete blood count (CBC) B-type natriuretic peptide (BNP) Serum electrolytes Blood urea nitrogen (BUN)

B-type natriuretic peptide (BNP) The BNP level is a key diagnostic indicator of HF; high levels are a sign of high cardiac filling pressure and can aid in both the diagnosis and management of HF (Institute for Clinical Systems Improvement [ICSI], 2011).

The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply. Avoid all physical activity. Carry nitroglycerin at all times. Balance rest with activity. Stop smoking. Follow a diet high in saturated fats.

Balance rest with activity. Stop smoking. Carry nitroglycerin at all times. Managing angina pectoris at home includes balancing rest with activity, participating in a regular daily program of activities that do not induce angina pain, stopping smoking, carrying nitroglycerin at all times, and following a diet low in saturated fat.

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? Comminuted Simple Basilar Depressed

Basilar Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following? Fluid overload Hyperthermia Hemolytic transfusion reaction Cardiac arrest

Cardiac arrest Blood must be warmed in a commercial blood warmer because administration of large amounts of blood that has been refrigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy. Hyperthermia, hemolytic transfusion reaction, or fluid overload is not the concern.

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following? "Have you experienced any ptosis in the last few weeks?" "Have you experienced any viral infections in the last month?" "Have you had difficulty with urination in the last 6 weeks?" "Have you developed any new allergies in the last year?"

"Have you experienced any viral infections in the last month?" An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.

A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic? "Spike" on the rhythm strip Quality of the pulse Vibration under the skin Scar on the chest

"Spike" on the rhythm strip Confirmation that the client has a permanent pacemaker is the characteristic "spike" identified by a thin, straight stroke on the rhythm strip. The scar on the chest is suggestive of pacer implantation but not definitive. There should be no change in pulse quality, and no vibration under the skin.

The nurse and a nursing student are admitting a client with a malignant glioma brain tumor preoperatively for resection of the tumor. The nursing student asks the nurse, " I was told these types of tumors have a very poor prognosis. Why is the tumor being resected?" Which rationale for this intervention is true? - "Using this procedure will eliminate the need for chemotherapy." - "Surgical resection of the tumor will decrease intracranial pressure." - "Every life-saving treatment is administered when treating brain tumors." - "Removing bulk from the tumor will reverse the paralysis."

"Surgical resection of the tumor will decrease intracranial pressure." For clients with malignant glioma, complete removal of the tumor and cure are not possible, but the rationale for resection includes relief of intracranial pressure, removal of any necrotic tissue, and reduction in the bulk of the tumor, which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy. Due to the poor prognosis with this tumor, it is not likely that the surgical resection is considered a life-saving measure. Rather the surgical intervention is a means to manage symptoms in the palliative phase of the client's disease. Surgical resection does not eliminate the need for chemotherapy. Due to the malignant nature of this tumor, the surgery will not completely eliminate the tumor, but chemotherapy can be administered to eradicate or slow further cell growth to promote comfort in the palliative phase of the disease. In the case of this client, reversal of paralysis caused by brain tumor compression 6 months ago is not possible. This would not be the aim of the surgical resection.

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? "TIA is a warning sign. Let's talk about lowering your risks." "People who experience a TIA will develop a stroke". "TIA symptoms are short-lived and resolve within 24 hours". "I sense that you are happy it was not a stroke".

"TIA is a warning sign. Let's talk about lowering your risks." TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? "Cardioversion is done on a beating heart; defibrillation is not." "Cardioversion is always attempted before defibrillation because it has fewer risks." "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." "The difference is the timing of the delivery of the electric current."

"The difference is the timing of the delivery of the electric current." One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the client's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first.

The nurse is caring for a client newly diagnosed with a primary brain tumor. The client asks the nurse where the tumor came from. What would be the nurse's best response? "Your tumor likely started out in one of your glands." "Your tumor originated from somewhere outside the CNS." "Your tumor originated from cells within your brain itself." "Your tumor is from nerve tissue somewhere in your body."

"Your tumor originated from cells within your brain itself." Primary brain tumors originate from cells and structures within the brain. Secondary brain tumors are metastatic tumors that originate somewhere else in the body. The scenario does not indicate that the client's tumor is a pituitary tumor or a neuroma.

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome? 3 hours 6 hours 9 hours 12 hours

3 hours Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months. Some scientific statements have endorsed its expanded use for up to 4.5 hours.

The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. Which physical characteristic would the nurse most likely observe in this client? A moon face A barrel chest Long, thin fingers Signs of oxygen toxicity

A barrel chest In chronic obstructive pulmonary disease (COPD) clients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The client with COPD is more likely to have finger clubbing, which is an abnormal rounded appearance of the fingertips, rather than long, thin fingers. Clubbed fingers are the result of chronically low blood levels of oxygen. A moon face is swelling of the face due to increased fat deposits. This may be a sign of Cushing syndrome or a side effect of steroid use. Signs of oxygen toxicity, such as facial pallor or behavioral changes, may be possible but are not the most likely physical findings for this client.

One of the nuclear power plants experiences a crack in the protection of the core when the cooling system malfunctions. The thought is that the cooling system was tampered with. Healthcare facilities in the area are inundated with victims residing in the area around the power plant. What category of disaster would this be? A biologic disaster A chemical disaster A nuclear blast A radiologic disaster

A radiologic disaster The devices that initiate, control, and sustain the nuclear reactions as well as spent fuel are a potential concern for the escape of radiation. The scenario described does not indicate option A, B, or C; therefore, they are incorrect.

In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? Acetylcholine Dopamine Norepinephrine Epinephrine

Acetylcholine In MG, there is a reduction in the number of acetylcholine receptor sites because antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the neuromuscular junction. There are no decreased receptor sites of epinephrine, norepinephrine, or dopamine implicated in MG.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and gamma-aminobutyric acid are not receptor sites that are attacked in myasthenia gravis.

A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder? Acute renal failure Acute glomerulonephritis Nephrotic syndrome Chronic renal failure

Acute glomerulonephritis Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.

A homeless person is admitted the ED during a blizzard, and is unable to feel the feet and lower legs. Core temperature is noted at 33.2°C (91.8ºF). The client is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this client? Addressing the client's frostbite in his lower extremities Addressing the client's alcohol intoxication Addressing the client's malnutrition Addressing the client's hypothermia

Addressing the client's hypothermia The client may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the client's survival.

A school nurse is caring for a 10-year-old client who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction?

Administer an inhaled beta-adrenergic agonist. Asthma exacerbations are best managed by early treatment and education of the client. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in clients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.

A group of medical nurses are being certified in their response to potential bioterrorism. The nurses learn that if a client is exposed to the smallpox virus he or she becomes contagious at what time? 6 to 12 hours after exposure After a rash appears When the client becomes febrile When pustules form

After a rash appears A client is contagious after a rash develops, which initially develops on the face, mouth, pharynx, and forearms. The client exposed to the smallpox virus is not contagious immediately after exposure; only when pustules form, or with a body temperature of 38°C.

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? Tension pneumothorax Increased drainage Tidaling Air leak

Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

Which disease includes loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem? Alzheimer disease Huntington disease Amyotrophic lateral sclerosis Parkinson disease

Amyotrophic lateral sclerosis Amyotrophic lateral sclerosis (ALS) is a disease of unknown cause in which there is a loss of motor neurons in the anterior horns of the spinal cord and the motor nuclei of the lower brain stem. Parkinson disease is a slowly progressing neurologic movement disorder that eventually leads to disability. Alzheimer disease is a chronic, progressive, and degenerative brain disorder that is accompanied by profound effects on memory, cognition and ability for self-care. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia.

Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. Hyperalbuminemia Metabolic alkalosis Anemia Hyperkalemia Hypocalcemia

Anemia Hyperkalemia Hypocalcemia Hyperkalemia is due to decreased potassium excretion and excessive potassium intake. Metabolic acidosis results from decreased acid secretion by the kidney. A damaged glomerular membrane causes excess protein loss

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements? Mestinon therapy is initiated. Immune globulin is given intravenously. The thymus gland is removed. Antibodies are removed from the plasma.

Antibodies are removed from the plasma. Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.

A patient has been diagnosed with hyphema. Which of the following medicationclassifications stabilizes clot formation at the site of hemorrhage? Corticosteroids Diuretics Antifibrinolytics Antiplatelets

Antifibrinolytics An antifibrinolytic agent, aminocaproic acid (Amicar), stabilizes clot formation at the site of hemorrhage. Corticosteroids, antiplatelets, and diuretics do not have this action. Aspirin is contraindicated.

The nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess? Fluid intake for the last 24 hours Electrocardiogram (ECG) results Arterial blood gas (ABG) levels Prior outcomes of weaning

Arterial blood gas (ABG) levels Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins

A client with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? - Utilize the vascular access site for infusion of IV fluids. - Change the dressing over the vascular access site at least every 12 hours. - Assess for a thrill or bruit over the vascular access site each shift. - Ensure that the client moves the extremity with the vascular access site as little as possible.

Assess for a thrill or bruit over the vascular access site each shift. The bruit, or "thrill," over the venous access site must be evaluated at least every shift. Frequent dressing changes are unnecessary and the client does not normally need to immobilize the site. The site must not be used for purposes other than dialysis.

A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse? Document the effectiveness of medications. Irrigate the ear. Educate the client on the therapeutic effects of medications. Assess the tympanic membrane.

Assess the tympanic membrane. A client diagnosed with otitis media who feels sudden relief of pain and/or pressure should be assessed for a tympanic membrane rupture. Educating the client on the therapeutic effects of medications is appropriate for newly diagnosed otitis media, but it does not address the sudden disappearance of pain and pressure. Because the medication usually takes 48 to 72 hours to be effective, documenting the medication as effective would be inappropriate. It is not necessary to irrigate an ear with otitis media.

A client is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? Amyl nitrate Erythromycin Dimercaprol Atropine

Atropine Atropine is administered when a client is exposed to a nerve agent. Exposure to blood agents, such as cyanide, requires treatment with amyl nitrate, sodium nitrite, and sodium thiosulfate. Dimercaprol is administered IV for systemic toxicity and topically for skin lesions when exposed to vesicants. Erythromycin is an antibiotic, which is ineffective against nerve agents.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Administer inotropic drugs Attach a cardiac monitor Assist with endotracheal intubation Insert a Foley urinary catheter

Attach a cardiac monitor Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

Which phase of a migraine headache usually lasts less than an hour? Premonitory Headache Aura Postdrome

Aura The aura phase occurs in about 20% of clients who have migraines and may be characterized by focal neurological symptoms. The premonitory phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the postdrome phase, clients may sleep for extended periods.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? Auscultate the lung for adventitious sounds. Have the patient cough. Have the patient inform the nurse of the need to be suctioned. Assess the CO2 level to determine if the patient requires suctioning.

Auscultate the lung for adventitious sounds. When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication?

Autonomic dysfunction Based on the assessment data, potential complications that may develop include respiratory failure and autonomic dysfunction. Skin breakdown, decreased cognition, and hemorrhage are not complications of Guillain-Barré syndrome.

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Autonomic dysreflexia Paraplegia Areflexia Tetraplegia

Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

The nurse is providing discharge instructions to a client after a permanent pacemaker insertion. Which safety precaution will the nurse communicate to the client? Stay at least 5 feet away from microwave ovens. Avoid undergoing magnetic resonance imaging (MRI). Never engage in activities that require vigorous arm and shoulder movement. Avoid going through airport metal detectors.

Avoid undergoing magnetic resonance imaging (MRI). A client with a pacemaker should avoid undergoing an MRI because the magnet could disrupt pacemaker function and cause injury to the client. Disruption is less likely to occur with newer microwave ovens. The client must avoid vigorous arm and shoulder movement only for the first 6 weeks after pacemaker implantation. Airport metal detectors don't harm pacemakers; however, the client should notify airport security guards that he has a pacemaker because its metal casing and programming magnet could trigger the metal detector.

Which of the following types of skull fractures may be evident by Battle's sign? Simple Comminuted Depressed Basilar

Basilar A clinical manifestation of a basilar skull fracture is the Battle's sign (an area of ecchymosis may be seen over the mastoid). A simple (linear) fracture is a break in continuity of the bone. A comminuted skull fracture refers to a splintered fracture line. When bone fragments are embedded into the brain tissue, the fracture is depressed.

A client has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this client? Bleeding at the implantation site Malignant hyperthermia Chest pain Bradycardia

Bleeding at the implantation site Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.

The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate? Inability to produce sufficient tears Blurred or cloudy vision A burning sensation and the sensation of an object in the eye A swollen lacrimal caruncle

Blurred or cloudy vision When a cataract forms, the light is blocked from reaching the macula and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle.

A patient has had cardiac surgery and is being monitored in the intensive care unit (ICU). What complication should the nurse monitor for that is associated with an alteration in preload? Elevated central venous pressure Cardiac tamponade Hypertension Hypothermia

Cardiac tamponade Preload alterations occur when too little blood volume returns to the heart as a result of persistent bleeding and hypovolemia. Excessive postoperative bleeding can lead to decreased intravascular volume, hypotension, and low cardiac output. Bleeding problems are common after cardiac surgery because of the effects of cardiopulmonary bypass, trauma from the surgery, and anticoagulation.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? Nonproductive cough and abdominal pain Hypertension and lack of fever Chest pain and dyspnea Bradypnea and bradycardia

Chest pain and dyspnea As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism

A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take? Rocephin (Ceftriaxone) IV for 7 days Erythromycin for 2 weeks Ciprofloxacin (Cipro) for 60 days Penicillin G IM for 1 dose

Ciprofloxacin (Cipro) for 60 days At present, anthrax is penicillin sensitive; however, strains of penicillin-resistant anthrax are thought to exist. Recommended treatment includes penicillin ( Penicillin V), erythromycin (Erythrocin), gentamicin ( Garamycin), or doxycycline (Vibramycin). If antibiotic treatment begins within 24 hours after exposure, death can be prevented. In a mass casualty situation, treatment with ciprofloxacin (Cipro) or doxycycline is recommended, because these easily administered oral antibiotic agents are stockpiled and there should be sufficient dosages to fully treat many anthrax-exposed patients.

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? Increased urine output Decreased heart rate Cool, clammy skin Hyperactive bowel sounds

Cool, clammy skin In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

A nurse is providing education about hypertension to a community group. What are possible consequences of untreated hypertension? Select all that apply. Coronary artery disease Myocardial infarction Stroke Pancreatitis Tension pneumothorax

Coronary artery disease Myocardial infarction Stroke People with hypertension may remain asymptomatic for many years. When specific signs and symptoms appear, however, they usually indicate vascular damage. Coronary artery disease with angina and myocardial infarction are common consequences of hypertension. Cerebrovascular involvement may lead to a stroke. Tension pneumothorax and pancreatitis are not directly related to hypertension.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? Administering oxygen, coughing, breathing deeply, and maintaining bed rest Administering pain medications, frequent repositioning, and limiting fluid intake Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention? Defibrillation Implantation of a cardioverter defibrillator Angioplasty ECG monitoring

Defibrillation Any type of VT in a client who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia.

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? Diaphoresis Bradycardia Temperature of 101 degrees F (38 degrees C) Delirium

Delirium Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? Adrenal crisis Cushing syndrome Syndrome of inappropriate antidiuretic hormone (SIADH) Diabetes insipidus

Diabetes insipidus Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the client becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

A client with mitral stenosis comes to the physician's office for a routine checkup. When listening to the client's heart, the nurse expects to hear which type of murmur? Pansystolic, blowing, high-pitched Diastolic, rumbling, low-pitched Systolic, harsh, crescendo-decrescendo Diastolic, blowing, decrescendo

Diastolic, rumbling, low-pitched Mitral stenosis causes a diastolic, rumbling, low-pitched murmur audible at the apex. A pansystolic, blowing, high-pitched murmur characterizes mitral insufficiency. A systolic, harsh, crescendo-decrescendo murmur occurs with aortic stenosis. A diastolic, blowing, decrescendo murmur accompanies aortic insufficiency.

The nurse is assessing a client admitted with renal stones. During the admission assessment, what parameters should the nurse address? Select all that apply. Medication history Family history of renal stones Dietary history Surgical history Vaccination history

Dietary history Family history of renal stones Medication history Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the client to stone formation. When caring for a client with renal stones, it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones.

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of: Generalized fatigue. Facial muscle weakness. Diplopia. Dysphoria.

Diplopia. The initial manifestation of MG usually involves the ocular muscles. Diplopia (double vision) and ptosis (drooping of the eyelids) are common. The majority of patients also experience weakness of the muscles of the face and throat, generalized weakness, and weakness of the facial muscles.

A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? Elevated ST segment Prolonged PR interval Widened QRS complex Absent Q wave

Elevated ST segment Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. Obtain daily weights to monitor weight gain. Ensure access to a language board when communicating with the client. Encourage the client to walk with feet wide apart. Establish a voiding time schedule.

Ensure access to a language board when communicating with the client. Establish a voiding time schedule. Encourage the client to walk with feet wide apart. Language assistive devices may be needed if communication is severely affected. Occasional bladder incontinence may lead to total incontinence. A voiding time schedule will allow the client greater independence. If motor dysfunction causes problems of incoordination and clumsiness, the patient is at risk for falling. As the disease progresses, nutritional deficiencies may develop. Weight should be assessed to ensure that there is no significant weight loss. Weight gain should not be an issue.

A client is brought to the ED by friends. The friends tell the nurse that the client was using cocaine at a party. On arrival to the ED the client is in visible distress with an axillary temperature of 40.1ºC (104.2°F). What would be the priority nursing action for this client? Administer antipyretics. Ensure airway and ventilation. Prevent seizure activity. Monitor cardiovascular effects.

Ensure airway and ventilation. Although all of the listed actions may be necessary for this client's care, the priority is to establish a patent airway and adequate ventilation.

A nurse is caring for a client with aortic stenosis whose compensatory mechanisms of the heart have begun to fail. The nurse will monitor the client carefully for which initial symptoms?

Exertional dyspnea, orthopnea, pulmonary edema When symptoms develop, clients with aortic stenosis usually first have exertional dyspnea, caused by increased pulmonary venous pressure from left heart failure. Orthopnea, paroxysmal nocturnal dyspnea, dizziness, and pulmonary edema may also occur. Nausea and vomiting may be signs of gastrointestinal congestion, but would be related to right heart failure, which does not occur initially with aortic stenosis.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Talk in a louder than normal voice. Keep the television on while she speaks. Face the client and establish eye contact. Use one long sentence to say everything that needs to be said.

Face the client and establish eye contact. When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal

An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? PR interval is constant. Fewer QRS complexes than P waves PP interval and RR interval are irregular. PP interval is equal to RR interval.

Fewer QRS complexes than P waves In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes are not consistent with this diagnosis.

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? Fluid restriction Transfusion of platelets Electrolyte restriction Transfusion of fresh frozen plasma (FFP)

Fluid restriction The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse? Apply a tourniquet to the arm above the bite. Have the patient lie down and place the arm below the level of the heart. Apply ice to the area. Make an incision and suck the venom out.

Have the patient lie down and place the arm below the level of the heart. Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe? Headache and nuchal rigidity Numbness and vomiting Hyporeflexia in the lower extremities Ptosis and diplopia

Headache and nuchal rigidity Headache and fever are the initial symptoms of meningitis. Nuchal rigidity can be an early sign. Photophobia is also a well-recognized sign in meningitis. Ptosis and diplopia are usually seen with myasthenia gravis. Hyporeflexia in the legs is seen with Guillain-Barre syndrome

A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin? Headache, hypotension, dizziness, and flushing. Sedation, nausea, vomiting, constipation, and respiratory depression. Flushing, dizziness, headache, and pedal edema. Nausea, vomiting, depression, fatigue, and impotence.

Headache, hypotension, dizziness, and flushing. Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Vasodilators, beta-adrenergic blockers, and calcium channel blockers are three major classes of drugs used to treat angina pectoris. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a beta-adrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic that relieves pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker

The nurse is caring for a client with cardiac compromise related to mitral valve impairment. Which outcome of the eroding of the mitral valve is most significant? Activity intolerance Pulmonary congestion Presence of a heart murmur Heart failure

Heart failure The most significant outcome of the eroding of the mitral valve is heart failure. Blood leaking between the heart chambers diminishes the hearts ability to circulate blood efficiently. Eventually, the heart cannot keep up with the body's metabolic need, and heart failure occurs.

Which is the most common motor dysfunction seen in clients diagnosed with stroke? Diplopia Hemiplegia Hemiparesis Ataxia

Hemiplegia The most common motor dysfunction is hemiplegia (paralysis of one side of the body) caused by a lesion on the opposite side of the brain. Ataxia is impaired ability to coordinate movement. Diplopia is double vision. Hemiparesis is weakness of one side of the body.

The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take? Check with the dialysis nurse about the medications. Hold the medications until after dialysis. Ask if the client wants to take the medications. Administer the medications as ordered.

Hold the medications until after dialysis. Antihypertensive therapy, often part of the regimen of clients on dialysis, is one example when communication, education, and evaluation can make a difference in client outcomes. The client must know when—and when not—to take the medication. For example, if an antihypertensive agent is taken on a dialysis day, hypotension may occur during dialysis, causing dangerously low blood pressure. Many medications that are taken once daily can be held until after dialysis treatment

The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis?

Hot, dry skin Heat stroke is manifested by hot, dry skin, confusion, bizarre behavior, coma, elevated body temperature (usually 103°F/39.4°C or higher), tachypnea, hypotension, and tachycardia. A widening pulse pressure is more indicative of a heart defect or problem. Cheyne-Stokes respirations, a rare condition characterized by fast, shallow breathing followed by slow heavier breathing, followed by no breathing, are typically seen in clients with heart failure and stroke.

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? Male gender African heritage Hypertension Advanced age

Hypertension Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Non-modifiable risk factors include advanced age, gender, and race.

The nurse is caring for a client in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The client has become hypotensive. What is the cause of this complication to the ARDS treatment? Pulmonary hypotension due to decreased cardiac output Hypovolemia secondary to leakage of fluid into the interstitial spaces Severe and progressive pulmonary hypertension Increased cardiac output from high levels of PEEP therapy

Hypovolemia secondary to leakage of fluid into the interstitial spaces Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the client becoming hypotensive.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. Obstructive shock; kidney stone Neurogenic shock; diabetes Septic shock; infection Cardiogenic shock; myocardial infarction Hypovolemic shock; blood loss Anaphylactic shock; nut allergy

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the client's frostbite? - Immerse the client's frostbitten extremities in the warmest water the client can tolerate. - Immerse affected extremities in water slightly above normal body temperature. - Perform passive range-of-motion exercises of the affected extremities to promote circulation. - Gently massage the client's frozen extremities in between water baths.

Immerse affected extremities in water slightly above normal body temperature. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? Impaired oral mucous membranes Activity intolerance Impaired gas exchange Imbalanced nutrition: Less than body requirements

Impaired gas exchange Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client.

The nurse is providing discharge teaching to a client with a spinal cord tumor and instructs the client to avoid hot water bottles and heating blankets for what reason? Motor weakness Impaired sensory perception Cognitive impairment Medication side effects

Impaired sensory perception Clients with residual sensory involvement are cautioned about the dangers of extremes in temperature. They should be educated about the dangers of heating devices (e.g., hot water bottles, heating pads, space heaters) as their sensory integration may be impaired, causing them to lose the ability to detect dangerous stimulations and to react appropriately. Discharge teaching for motor weakness involves learning different ways to manage activities of daily living and possible teaching regarding the use of assistive devices such as a cane. Medications used in the treatment of spinal tumors would not predispose the client to diminished sensory integration; this problem arises from brain structure and spinal cord compression. Although cognitive impairment may be sequelae resulting from the growth and treatment of brain and spinal tumors, the primary reason clients are instructed not to use excessive temperatures is because they may have lost of ability to sense extremes of hot and cold.

Which is the most important postoperative assessment parameter for a client recovering from cardiac surgery?

Inadequate tissue perfusion The nurse must assess the client for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood glucose and mental status, tissue perfusion is the higher priority. Assessing for activity intolerance, while important later in the recovery period, is not essential in the immediate postoperative period for clients undergoing cardiac surgery.

What is a characteristic of the intrarenal category of acute renal failure? Increased BUN High specific gravity Decreased urine sodium Decreased creatinine

Increased BUN The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.

The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client? Hypervolemia Hypovolemia Decreased intracranial pressure Increased intracranial pressure

Increased intracranial pressure Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that volume either increasing or decreasing is an issue.

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? Activity intolerance Acute pain Ineffective breathing pattern Excess fluid volume

Ineffective breathing pattern Ineffective breathing pattern takes priority for a client with a pulmonary contusion with a pulmonary embolism. The objective of immediate management is to restore and maintain cardiopulmonary function. After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is necessary. Fluid volume, pain, and activity intolerance are not priority concerns.

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? Nebulizer and thermometer Incentive spirometer Intubation tray and suction apparatus Blood pressure apparatus

Intubation tray and suction apparatus Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.

The staff educator is teaching a class in arrhythmias. What statement is correct for defibrillation? It uses less electrical energy than cardioversion. The client is sedated before the procedure. It is a scheduled procedure 1 to 10 days in advance. It is used to eliminate ventricular arrhythmias.

It is used to eliminate ventricular arrhythmias. The only treatment for a life-threatening ventricular arrhythmia is immediate defibrillation, which has the exact same effect as cardioversion, except that defibrillation is used when there is no functional ventricular contraction. It is an emergency procedure performed during resuscitation. The client is not sedated but is unresponsive. Defibrillation uses more electrical energy (200 to 360 joules) than cardioversion.

A new client has been admitted with right-sided heart failure. When assessing this client, the nurse knows to look for which finding? Pulmonary congestion Jugular venous distention Cough Dyspnea

Jugular venous distention When the right ventricle cannot effectively pump blood from the ventricle into the pulmonary artery, the blood backs up into the venous system and causes jugular venous distention and congestion in the peripheral tissues and viscera. All the other choices are symptoms of left-sided heart failure.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A change in the oxygen concentration without resetting the oxygen level alarm An ET cuff leak A disconnected ventilator circuit Kinking of the ventilator tubing

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?.. Lactated Ringer's 0.9% sodium chloride Albumin Dextran

Lactated Ringer's Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

Which feature is the hallmark of systolic heart failure? Pulmonary congestion Limited activities of daily living (ADLs) Low ejection fraction (EF) Basilar crackles

Low ejection fraction (EF) A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which organ?

Lungs During MODS, the organ failure usually begins in the lungs and is followed by failure of the liver, gastrointestinal system, and kidneys.

An older adult patient has noticed a significant amount of vision loss in the last few years. What does the nurse recognize as the most common cause of visual loss in older adults? Retinal vascular disease Uveitis Macular degeneration Ocular trauma

Macular degeneration Age-related macular degeneration is the most common cause of visual loss in people older than 65 years in the United States (Prevent Blindness America, 2011b).

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? Establishing balanced nutrition Involvement with diversion activities Maintaining a safe environment Enhancement of the immune system

Maintaining a safe environment The primary focus in caring for Parkinson's disease is on maintaining a safe environment. Parkinson's disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.

What is histamine, a mediator that supports the inflammatory process in asthma, secreted by? Mast cells Eosinophils Neutrophils Lymphocytes

Mast cells Mast cells, neutrophils, eosinophils, and lymphocytes play key roles in the inflammation associated with asthma. When activated, mast cells release several chemicals called mediators. One of these chemicals is called histamine.

The nurse is administering antivenin to a patient who was bitten on the arm by a venomous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? Measure the circumference of the arm. Administer cimetidine (Tagamet). Assess peripheral pulses. Administer diphenhydramine (Benadryl).

Measure the circumference of the arm. Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Keeping the collection chamber at chest level Stripping the chest tube every hour Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber

Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Catheter occlusion Cerebral spinal fluid leak Encephalitis Meningitis

Meningitis Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a cerebral spinal fluid (CSF) leak, or an occluded catheter.

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? Multiple sclerosis Parkinson disease Creutzfeldt-Jakob disease Huntington disease

Multiple sclerosis The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? Flumazenil N-acetylcysteine Diazepam Naloxone

N-acetylcysteine Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

Which medication reverses severe respiratory depression and coma? Naloxone hydrochloride Diazepam Flumazenil N-acetylcysteine

Naloxone hydrochloride Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Diazepam is a benzodiazepine. Flumazenil is a benzodiazepine antagonist. N-acetylcysteine is used for acetaminophen toxicity.

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? Numbness and tingling in the lower extremities Neck flexion produces flexion of knees and hips Inability to stand with eyes closed and arms extended without swaying Pain upon ankle dorsiflexion of the foot

Neck flexion produces flexion of knees and hips Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

Which chemical is a vesicant? Nitrogen mustard Sarin Chlorine Hydrogen cyanide

Nitrogen mustard Examples of vesicants are phosgene, nitrogen mustard, and sulfur mustard. Sarin is a nerve agent. Hydrogen cyanide is a blood agent. Chlorine is a pulmonary agent.

A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include? Limit fluid intake to reduce the need to urinate. Take medication ordered for a UTI until the symptoms subside. Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. Wear only nylon underwear to reduce the chance of irritation.

Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. The client should notify the physician so that a microscopic urinalysis can be done and appropriate treatment can be initiated. The client should be instructed to drink 2 to 3 L of fluid per day to dilute the urine and reduce irritation of the bladder mucosa. To prevent UTI recurrence, the full amount of antibiotics ordered must be taken despite the fact that the symptoms may have subsided. Women are told to avoid scented toilet tissue and bubble baths and to wear cotton underwear, not nylon, to reduce the chance of irritation

The nurse is caring for a client with aortic regurgitation. The nurse knows to expect what symptoms during the physical examination? Nausea and low urine output Headache and vomiting Increased urine output Orthopnea and dyspnea

Orthopnea and dyspnea Aortic regurgitation usually manifests as progressive left ventricular failure, resulting from blood flowing backward from the aorta to the left ventricle, and eventually into the lungs. Urine output would be decreased from lower cardiac output. Nausea and vomiting are symptoms of increased gastrointestinal pressure, which would result from right heart failure. Kidney failure could become a problem later if cardiac output became too low, but not initially. CVA and an infarcted bowel would not be caused by mitral regurgitation.

Clinical characteristics of neurogenic shock are noted by which type of stimulation? Cerebral Parasympathetic Endocrine Sympathetic

Parasympathetic The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The client experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation.

The nurse is assigned the care of a 30-year-old client diagnosed with cystic fibrosis (CF). Which nursing intervention will be included in the client's care plan? Restricting oral intake to 1,000 mL/day Providing the client a low-sodium diet Discussing palliative care and end-of-life issues with the client Performing chest physiotherapy as ordered

Performing chest physiotherapy as ordered Nursing care includes helping clients manage pulmonary symptoms and prevent complications. Specific measures include strategies that promote removal of pulmonary secretions, chest physiotherapy, and breathing exercises. In addition, the nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Clients with CF also experience increased salt content in sweat gland secretions; thus it is important to ensure the client consumes a diet that contains adequate amounts of sodium. As the disease progresses, the client will develop increasing hypoxemia. In this situation, preferences for end-of-life care should be discussed, documented, and honored; however, there is no indication that the client is terminally ill.

A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. Atelectasis Bronchospasm Pneumothorax Air embolism Infection

Pneumothorax Infection Air embolism Complications from use of hemodynamic monitoring systems are uncommon, but can include pneumothorax, infection, and air embolism. Complications of hemodynamic monitoring systems do not include atelectasis or bronchospasm.

The instructor is talking with a nursing student who is caring for a client with pericarditis. The instructor asks the student to name the main characteristic of pericarditis. What should be the student's answer? Dyspnea Respiratory symptoms Fever Precordial pain

Precordial pain Precordial pain is the main characteristic of pericarditis. Dyspnea, fever, and respiratory symptoms are not the main characteristics of pericarditis.

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? Progressive Compensatory Refractory Irreversible

Progressive In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? Progressive loss of lung function associated with chronic disease Sudden loss of lung function associated with chronic disease Progressive loss of lung function with history of normal lung function Sudden loss of lung function with history of normal lung function

Progressive loss of lung function associated with chronic disease In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease.

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder? Prolonged use of corticosteroids Age younger than 40 years Hyperopia since age 20 years History of respiratory disease

Prolonged use of corticosteroids Risk factors associated with glaucoma include prolonged use of topical or systemic corticosteroids, older age, myopia, and a history of cardiovascular disease.

A client the nurse is caring for experiences a seizure. What would be a priority nursing action? Insert a tongue blade between the teeth. Restrain the client during the seizure. Protect the client from injury. Suction the mouth during the convulsion.

Protect the client from injury. The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.

The critical care nurse is caring for a client who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the client's left ventricular function? Pulmonary artery pressure monitoring (PAPM) Central venous pressure (CVP) monitoring Systemic arterial pressure monitoring (SAPM) Arterial blood gases (ABGs)

Pulmonary artery pressure monitoring (PAPM) Pulmonary artery pressure monitoring is used to assess left ventricular function. CVP is used to assess right ventricular function; systemic arterial pressure monitoring is used for continual assessment of BP. ABGs are used to assess for acidic and alkalotic levels in the blood.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? Pulmonary congestion Nausea Pedal edema Jugular venous distention

Pulmonary congestion When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Congestive heart failure Pneumonia Panic attack

Pulmonary edema The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? Rapid, jerky, involuntary movements Dysphagia and dysphonia Slow, shuffling gait Dementia

Rapid, jerky, involuntary movements The most prominent clinical features of the disease are chorea (rapid, jerky, involuntary, purposeless movements), impaired voluntary movement, intellectual decline, and often personality changes (Aubeeluck & Wilson, 2008).

A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client? Reduce hypertension and high blood cholesterol Increase intake of proteins and carbohydrates Increase body weight moderately Increase hydration and the intake of fluids

Reduce hypertension and high blood cholesterol CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias like atrial fibrillation, and high blood cholesterol. Clients should not gain body weight. In addition, increased intake of proteins, carbohydrates, or fluids does not help reduce the risk of CVAs.

A male patient with cerebrovascular accident (CVA) is prescribed medication to treat the disorder. The patient wants to know what other measures may help reduce CVA. Which of the following is an accurate suggestion for the patient? Increase body weight moderately. Increase the fluids and hydration. Increase the intake of proteins and carbohydrates. Reduce hypertension and high blood cholesterol levels.

Reduce hypertension and high blood cholesterol levels. CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias (such as atrial fibrillation), and high blood cholesterol levels. Patients should not gain body weight. In addition, the increased intake of proteins, carbohydrates, or fluids does not help in reducing the risk of CVAs.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? Tachycardia Bradycardia Reduced cardiac output Increased blood pressure

Reduced cardiac output PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

Which terms describes the backward flow of blood through a heart valve?

Regurgitation Regurgitation is a backward flow of blood through a heart valve, a result of the valve not closing completely. Stenosis occurs when the valves don't open completely and the flow of blood through the valve is reduced. Hypertrophy is an enlargement of an organ. A prolapse is stretching of atrioventricular heart valve leaflet into the atrium during systole.

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory alkalosis Respiratory acidosis

Respiratory acidosis Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure. The other acid-base imbalances would not correlate with COPD.

The nurse is caring for a patient with status asthmaticus in the intensive care unit (ICU). What does the nurse anticipate observing for the blood gas results related to hyperventilation for this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis Respiratory alkalosis (low PaCO2) is the most common finding in patients with an ongoing asthma exacerbation and is due to hyperventilation.

A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care? Self-management of oxygen therapy Facilitation of long-term intubation Restoration of adequate gas exchange Attainment of effective coping

Restoration of adequate gas exchange The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.

It is important for a nurse to be aware of the normal hemodynamics of blood flow to recognize and understand pathology when it occurs. The nurse should know that incomplete closure of the tricuspid valve results in a backward flow of blood from the: Aorta to the left ventricle. Left atrium to the left ventricle. Right atrium to the right ventricle. Right ventricle to the right atrium.

Right ventricle to the right atrium. The tricuspid valve is located between the right atrium and the right ventricle. Therefore, incomplete closure results in the backward flow of blood from the right ventricle to the right atrium.

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?

Right-sided heart failure Signs and symptoms of Right Ventricular Failure include: Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention. The scenario does not indicate whether the heart failure is chronic or acute. Therefore, options A, B, and C are incorrect.

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure? Left-sided heart failure Chronic heart failure Acute heart failure Right-sided heart failure

Right-sided heart failure Signs and symptoms of Right Ventricular Failure include: Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention. The scenario does not indicate whether the heart failure is chronic or acute. Therefore, options A, B, and C are incorrect.

A client with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the client's plan of care? Disturbed body image related to urinary catheterization Risk for infection related to presence of an indwelling urinary catheter Deficient knowledge regarding indwelling urinary catheter care Impaired physical mobility related to presence of an indwelling urinary catheter

Risk for infection related to presence of an indwelling urinary catheter Fifty percent of all hospital-acquired infections are urinary tract infections (UTI), with a large number being associated with indwelling urinary catheters. This adverse infection is frequently referred to as a CAUTI (catheter associated urinary tract infection) and considered in the United States as a "never event." According to the National Quality Forum (NQF), never events are errors in health care that are identifiable, preventable, and serious for clients. Since the risk of infection is substantial; it is prioritized over functional and psychosocial diagnosis of mobility, knowledge deficits, and disturbed body image for this client

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family? Unilateral neglect Risk for injury Impaired spontaneous ventilation Risk for infection

Risk for injury Individuals with Parkinson disease face a significant risk for injury related to the effects of dyskinesia. Unilateral neglect is not characteristic of the disease, which affects both sides of the body. Parkinson disease does not directly constitute a risk for infection or impaired respiration.

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

Run a normal saline line to keep the vein open If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The "to keep vein open" (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions.

What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids? Sterile otitis media Purulent otitis media Serous otitis media Infectious otitis media

Serous otitis media Serous otitis media, a collection of pathogen-free fluid behind the tympanic membrane, results from irritation associated with respiratory allergies and enlarged adenoids. The other options are distractors for this question. Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections.

Which symptom occurs in the client diagnosed with mitral regurgitation when pulmonary congestion occurs? Shortness of breath A loud, blowing murmur Hypertension Tachycardia

Shortness of breath If pulmonary congestion occurs, the client with mitral regurgitation develops shortness of breath. A loud, blowing murmur often is heard throughout ventricular systole at the apex of the heart. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle. Tachycardia is a compensatory mechanism when stroke volume decreases

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as Dopamine Sodium nitroprusside Norepinephrine Furosemide

Sodium nitroprusside Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.

A 26-year-old client, who has been diagnosed with paroxysmal supraventricular tachycardia (PSVT), is treated in the emergency department. The client is experiencing occasional runs of PSVT lasting up to several minutes at a time. During these episodes, the client becomes lightheaded but does not lose consciousness. Which maneuver(s) may be used to interrupt the client's atrioventricular nodal reentry tachycardia (AVNRT)? Select all that apply. Stimulating the client's gag reflex Performing carotid massage Instructing the client to breathe deeply Placing the client's face in cold water Instructing the client to vigorously exercise

Stimulating the client's gag reflex Placing the client's face in cold water Performing carotid massage The following vagal maneuvers can be used to interrupt atrioventricular nodal reentry tachycardia (AVNRT): stimulating the client's gag reflex, having the client hold the breath, cough, bear down, placing the face in cold water, or performing carotid massage. These measures elicit a vagal response, which will slow AV conduction time and help restore a regular rhythm. Because of the risk of a cerebral embolic event, carotid massage is contraindicated in clients with carotid bruits. If the vagal maneuvers are ineffective, the client may receive a bolus of adenosine to correct the rhythm; this is nearly 100% effective in terminating AVNRT. Overexertion and deep inspirations are measures that could precipitate supraventricular tachycardia (SVT)

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? Intracerebral Epidural Subdural Cerebral

Subdural A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

Which of the following is a clinical manifestation of a pneumothorax? Select all that apply. Sudden chest pain Unilateral retractions Asymmetry of chest movement Oxygen desaturation Bilaterally equal breath sounds

Sudden chest pain Asymmetry of chest movement Unilateral retractions Oxygen desaturation Signs and symptoms of pneumothorax include sudden chest pain that is sharp and abrupt, a significant and sudden increase in shortness of breath, asymmetry of chest movement, unilateral retractions, bilateral differences in breath sounds, and/or oxygen desaturation. The patient with a pneumothorax would not have bilaterally equal breath sounds.

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? Emotional apathy Choreiform movements Loss of bowel and bladder control Suicidal ideations

Suicidal ideations Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these symptoms is appropriate, but not as important as assessing for suicidal ideations.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Tracheal cuff pressure set at 30 mm Hg Symmetry of the client's chest expansion Cool air humidified through the tube A scheduled time for deflation of the tracheal cuff

Symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T10 S2 T6 L4

T6 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

Which nursing action is appropriate for a home care nurse? Teaching pursed-lip breathing to a client diagnosed with chronic obstructive pulmonary disease (COPD) Volunteering to administer flu vaccinations and the local free clinic Organizing a free breast cancer screening for homeless women Writing a grant to obtain funding to establish a homeless shelter

Teaching pursed-lip breathing to a client diagnosed with chronic obstructive pulmonary disease (COPD) Tertiary prevention, focusing on rehabilitation and restoring maximum health function, is a goal for home care nurses. Pursed lipped breathing allows the client with COPD to control shortness of breath, making each breath more effective, and improves quality of life. Promoting the health of populations is a focus of community/public health nursing. The homeless population is increasing in the United States. Minimizing the progression of disease through early detection is one method that a community/public health nurse could use. Maintaining the health of populations through immunization clinics is a focus of the community/public health nurse.

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Pulmonary contusion Cardiac tamponade Tension pneumothorax Flail chest

Tension pneumothorax Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.

A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address? - The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest. - The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; therefore, the care plan should include reporting signs of premature labor. - The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity. - The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.

The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

A nurse is teaching a client about heart failure. What will the nurse explain is causing the heart to fail? The heart is fibrillating. The heart is pumping too fast to adequately meet the body's metabolic needs. The heart cannot pump sufficient blood to meet the body's metabolic needs. The heart is pumping too slow to disseminate nutrients to the body.

The heart cannot pump sufficient blood to meet the body's metabolic needs. Heart failure is the inability of the heart to pump sufficient blood to meet the body's metabolic needs. Heart failure does not mean the heart pumps too fast or to slow; it means it cannot contract effectively to eject the blood in the ventricles. A fibrillating heart involves a problem with conduction, not failure.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The chest tube is obstructed. The client has a pneumothorax. The system is functioning normally. The system has an air leak.

The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? Atorvastatin Extended release dipyridamole Tissue plasminogen activator (tPA) Clopidogrel

Tissue plasminogen activator (tPA) In 1996, the FDA approved the use of tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke within the first 3 hours of symptom onset.

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? To remove air from the pleural space To assist with mechanical ventilation To drain copious sputum secretions To monitor bleeding around the lungs

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 diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? Treatment with antimicrobial prophylaxis as soon as possible No treatment unless the roommate begins to show symptoms Bedrest at home for 72 hours Admission to the nearest hospital for observation

Treatment with antimicrobial prophylaxis as soon as possible People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.

Which of the following is the chief cause of intracerebral hemorrhage (ICH)? Migraine headaches Hypercholesterolemia Uncontrolled hypertension Diabetes

Uncontrolled hypertension Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension. Diabetes, hypercholesterolemia, and migraine headaches are not a chief cause of ICH.

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Tachypnea Unresponsive arterial hypoxemia Diminished alveolar dilation Increased PaO2

Unresponsive arterial hypoxemia Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.

When discussing diseases of the middle ear, the nursing instructor distinguishes the different types of otitis media. What generally causes purulent otitis media? Upper respiratory infections Bronchial tree Irritation associated with respiratory allergies and enlarged adenoids Outer ear

Upper respiratory infections Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections. It is not caused from the bronchial tree, the outer ear or irritation associated with respiratory allergies, and enlarged adenoids.

A client is being treated for bites suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? Apply a dressing saturated with chlorhexidine. Arrange for the client to receive a hepatitis B vaccination. Assess the client's immunization history. Wash the bites with soap and water.

Wash the bites with soap and water. After forensic evidence has been gathered, cleansing with soap and water is necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed. The client's immunization history does not directly influence the course of treatment and hepatitis B vaccination is not indicated. Chlorhexidine bandages are not recommended.

The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition? hemorrhage air embolism catheter-related bloodstream infections pneumothorax

catheter-related bloodstream infections Catheter-related bloodstream infections (CRBSIs) are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.

A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels?

distributive Distributive shock results from displacement of blood volume, creating pooling of blood in the peripheral blood vessels. Cardiogenic shock results from the failure of a heart as a pump. With hypovolemic shock, there is a decrease in the intravascular volume. Organ failure is not a type of shock.

A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess? anticoagulants. antiembolism stockings. diuretics. oxygen.

diuretics. Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess.

A patient is admitted with suspected cardiomyopathy. What diagnostic test will the nurse need to teach the client about for identification of this disease? cardiac catheterization phonocardiogram serial enzyme studies echocardiogram

echocardiogram The echocardiogram is one of the most helpful diagnostic tools for cardiomyopathy because the structure and function of the ventricles can be observed easily. Cardiac catheterization will focus on coronary vessels. The serial enzymes are done to detect heart muscle damage. The phonocardiogram is helpful for valve function.

A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply. blood volume decreases blunt force trauma nausea peripheral vascular dilation heart fails as effective pump

heart fails as effective pump blood volume decreases peripheral vascular dilation Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate (Wedro, 2014).

The critical care nurse is caring for a client with a central venous pressure (CVP) monitoring system. The nurse notes that the client's CVP is increasing. This may indicate: hypervolemia. hypomagnesemia. psychosocial stress. dislodgment of the catheter.

hypervolemia. CVP is a useful hemodynamic parameter to observe when managing an unstable client's fluid volume status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility. Stress, dislodgment of the catheter, and low magnesium levels would not typically result in increased CVP.

In a biologic attack with anthrax, which exposure route develops into the most severe form of anthrax? contact with contaminated objects ingestion skin infection inhalation

inhalation The most serious forms of anthrax develop by inhalation. At the onset, it may be mistaken for a cold or flu, but if it is diagnosed wrongly and untreated, the infection can progress to severe respiratory distress and almost certain death. Skin infection is the least deadly form and the only one that may be transmitted by direct contact. It is characterized by painless lesions usually on the head, hands, and arms that develop into black-centered blisters that eventually ulcerate. Although not the most serious form of exposure, ingesting the bacteria causes symptoms of nausea, vomiting, diarrhea, and abdominal pain as anthrax infects the gastrointestinal tract, circulatory system, and mesenteric lymph nodes. Contact with contaminated objects might cause an anthrax skin infection, the least deadly form of anthrax and the only one transmitted by direct contact.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. GERD kidney failure disseminated intravascular coagulation acute respiratory distress syndrome hypoglycemia

kidney failure disseminated intravascular coagulation acute respiratory distress syndrome When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? lisinopril diltiazem bumetanide cholestyramine

lisinopril Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with IV nitroglycerin. percutaneous coronary intervention (PCI). IV heparin. thrombolytics.

percutaneous coronary intervention (PCI). The client with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: place the client on his back, remove dangerous objects, and insert a bite block. place the client on his side, remove dangerous objects, and protect his head. place the client on his side, remove dangerous objects, and insert a bite block. place the client on his back, remove dangerous objects, and hold down his arms.

place the client on his side, remove dangerous objects, and protect his head. During the active seizure phase, the nurse should initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. Placing the client on his back and holding down the arms could cause injury to the client and the nurse.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis? excellent fatal good poor

poor An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.

The nurse encourages the client diagnosed with hypertension to rise slowly from a sitting or lying position because gradual changes in position - help reduce the work required by the heart to resupply oxygen to the brain. - provide time for the heart to increase the rate of contraction to resupply oxygen to the brain. - provide time for the heart to reduce the rate of contraction to resupply oxygen to the brain. - help reduce the blood pressure to resupply oxygen to the brain.

provide time for the heart to increase the rate of contraction to resupply oxygen to the brain. It is important for the nurse to encourage the client to rise slowly from a sitting or lying position because gradual changes in position provide time for the heart to increase its rate of contraction to resupply oxygen to the brain, not blood pressure or heart rate.

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of head injury. hypothermia. pulmonary edema. hyponatremia.

pulmonary edema. Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours.

Corticosteroids are used in the management of brain tumors to reduce cerebral edema. prevent extension of the tumor. identify precise location of the tumor. facilitate regeneration of neurons.

reduce cerebral edema. Corticosteroids may be used before and after treatment to reduce cerebral edema and promote a smoother, more rapid recovery. Corticosteroids do not prevent extension of the tumor or facilitate regeneration of neurons. Stereotactic procedures identify the precise location of the tumor

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because hypothermia can cause death. hypothermia is indicative of severe meningitis. shivering in hypothermia can increase ICP. hypothermia is indicative of malaria.

shivering in hypothermia can increase ICP. The nurse should avoid hypothermia in a client with increased ICP because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia in a client with ICP does not indicate malaria or meningitis and is not likely to cause death.

A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering: IV dextrose 50% Calcium supplements sodium polystyrene sulfonate (Kayexalate) Sorbitol

sodium polystyrene sulfonate (Kayexalate) The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract. Sorbitol may be administered in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract). If the client is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be administered to shift potassium back into the cells.

A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose? supraventricular tachycardia atrial flutter heart block sinus tachycardia

supraventricular tachycardia Supraventricular tachycardia (SVT) is a dysrhythmia in which the heart rate has a consistent rhythm but beats at a dangerously high rate (over 150 beats/minute). P waves cannot be identified on the ECG. Diastole is shortened and the heart does not have sufficient time to fill. These symptoms do not suggest sinus tachycardia, heart block, or atrial flutter.