Module 2 Review Questions

The client with a head injury is admitted into the intensive care unit (ICU). Which health-care provider medication order would the ICU nurse question? 1. Osmitrol (Mannitol), an osmotic diuretic. 2. Methylprednisolone (Solu-Medrol), a corticosteroid. 3. Phenytoin (Dilantin), an anticonvulsant. 4. Oxygen, 6 L via nasal cannula.

1. An osmotic diuretic is the treatment of choice to help decrease intracranial pres- sure that occurs with a head injury. CORRECT 2. Research supports the finding that clients with head injuries who are treated with anti-inflammatory corti- costeroids are 20% more likely to die within 2 weeks after the head injury than those who aren't so treated. The nurse should question this medication. 3.Seizures are a common complication of head injuries; therefore, an order for an anticonvulsant medication would be appropriate. 4.There is no reason for the nurse to ques- tion an order for oxygen—which is considered a medication—for a client with a head injury.

Which data should the nurse assess for the client with a seizure disorder who is taking valproate (Depakote)? 1. Creatinine and BUN. 2. White blood cell count. 3. Liver enzymes. 4. Red blood cell count.

1. Depakote does not cause nephrotoxicity. 2.Depakote does not cause blood dyscrasia. CORRECT 3. Hepatotoxicity is one of the possible adverse reactions to Depakote; therefore, the liver enzymes should be monitored. 4.Depakote does not affect the RBC count.

Which discharge instruction should the emergency room nurse discuss with the client that has sustained a concussion and is being discharged home? 1. Do not take any type of medication for at least 48 hours. 2. Take two acetaminophen (Tylenol) up to every 4 hours for a headache. 3. If experiencing a headache, take one hydrocodone (Vicodin) every 8 hours. 4. It is all right to take a couple of aspirin if experiencing a headache.

1. The client can take nonnarcotic analgesics if experiencing a headache. CORRECT 2. Tylenol can be taken for a headache in a patient who has sustained a concussion. If the Tylenol does not relieve the headache, the client should contact the health-care provider. 3. Narcotic analgesics should not be taken after a head injury because such medications may further depress neurological status. 4. Aspirin could lead to bleeding, and a client with a concussion does not need a chance of increased bleeding.

The client with a head injury is experiencing increased intracranial pressure. The neurosurgeon prescribes the osmotic diuretic mannitol (Osmitrol). Which intervention should the nurse implement when administering this medication? 1. Monitor the client's arterial blood gases during administration. 2. Do not administer if the client's blood pressure is less than 90/60. 3. Ensure that the client's cardiac status is monitored by telemetry. 4. Use a filter needle when administering the medication.

1. The client's ABGs are not affected by the administration of mannitol; therefore, there is no need to monitor them. 2. The client's blood pressure does not affect the administration of mannitol. 3. The client with a head injury would be in the intensive care unit receiving telemetry, but mannitol does not affect cardiac status. CORRECT 4. The nurse must use a filter needle when administering mannitol because crystals may form in the solution and syringe and be inadvertently injected into the client if a filter needle is not used.

A client has just arrived to the emergency department and has sustained burns on the front and back of the right arm and leg. The client weighs 64 kg. Using the Parkland burn formula, how much fluid should this client receive in the first 8 hours after the injury? A. 4,608 mL B. 1,152 mL C. 2,304 mL D. 3,456 mL

3,456 mL A nurse can estimate the % of the body surface area burned using the rule of 9's. Each arm (front and back) is 9%. Each leg is 18% front and back (9% front and 9% back). Therefore in this case 9 + 18 = 27%. Using the Parkland Burn formula (4 x kg x %): 4 x 64 x 27 = 6,912 mL. Half of this volume is to be given in the first 8 hours after the injury. Therefore the client should receive 3,456 mL in 8 hours.

The nurse is working in the emergency department when a 2-year-old is brought in with burns from the bath tub to both legs. The nurse knows that this constitutes burns to what percentage of the body? A. 30% B. 19% C. 9.50% D. 15%

30% Both legs for a child are 15% for a total of 30%. The equation is as follows: Anterior leg on a 2 year old (use the 1 year old #'s until they reach 5 years old) = 3.25% thigh + 2.5% lower leg + 1.75% foot = 7.5%. The posterior leg is the same, so 7.5% x 2 = 15% for one leg, and 30% for two legs.

The client with a seizure disorder is prescribed the anticonvulsant fosphenytoin (Cerebyx). Which interventions should the nurse discuss with the client? Select all that apply. 1. Instruct the client to wear a MedicAlert bracelet and carry identification. 2. Tell the client to not self-medicate with over-the-counter medications. 3. Encourage the client to decrease drinking of any type of alcohol. 4. Discuss the importance of maintaining good oral hygiene. 5. Explain the importance of maintaining adequate nutritional intake.

ANSWER 1,2,5 1. The client should wear a MedicAlert bracelet and carry identification so that a health-care provider and others possibly providing care know that the client has a seizure disorder. 2. The client should not take any over- the-counter medications without first consulting with the HCP or pharmacist because many medications interact with Cerebyx. 3. Alcohol and other central nerve depressants can cause an added depressive effect on the body and should be avoided, not just decreased. 4. Gingival hyperplasia (overgrowth of gums) is a side effect of Dilantin, not of Cerebyx. 5. Dilantin may cause anorexia, nausea, and vomiting; therefore, the client should maintain an adequate nutri- tional intake.

What is the nurse's priority assessment for a client during the first 48 hours following a major burn injury? 1. Hyponatremia and hypokalemia 2. Hyponatremia and hyperkalemia 3. Hypernatremia and hypokalemia 4. Hypernatremia and hyperkalemia

ANSWER 2 During the first 48 hours after a burn, capillary permeability increases, allowing fluids to shift from the plasma to the interstitial spaces. This fluid is high in sodium, causing a decrease in serum sodiumn levels. Potassium also leaks from the cells into the plasma, causing hyperkalemia.

A client is preparing to undergo spinal surgery. In which position should the nurse place the client to best prevent injury during the surgical procedure? A. Prone B. Lithotomy C. Sims' position D. Trendelenburg

ANSWER A A. Prone The nurse in the operating room must be familiar with the appropriate position for the client based on the procedure performed. Proper positioning is also important to keep the client safe during the procedure. A spinal procedure involves operating on the client's back, so the nurse should position the client prone with head turned to the side, with special padding provided for the face and neck. B. Lithotomy This position is not conducive to spinal surgery, because the back is not properly exposed or accessible for the surgeon. C. Sims' position This position is not conducive to spinal surgery, because the back is not properly exposed or accessible for the surgeon. D. Trendelenburg This position is not conducive to spinal surgery, because the back is not properly exposed or accessible for the surgeon.

An emergency department nurse is assessing a 12-year-old boy who has suffered a burn injury while helping his dad in the garage. The nurse performs a rapid initial assessment of the wounds and checks for signs of inhalation injury. Which of the following signs or symptoms would indicate an inhalation injury in this child? Select all that apply. A. Edematous oropharynx B. Burns to the neck and chest C. Singed nasal hairs D. Respiratory rate of 24/min

ANSWER A,B A. Edematous oropharynx Inhalation injury occurs when a person breathes in chemicals or certain substances that can burn the airway and respiratory tract. Inhalation may be more likely to occur with burn injuries, as burning substances often release smoke and gases that cause injury when inhaled. Signs or symptoms of an inhalation injury include facial burns, erythema, swelling of oropharynx and nasopharynx, sooty sputum, and hoarse voice. B. Burns to the neck and chest Burns to these areas do not mean that the client has an inhalation injury, as the neck and chest are far enough away anatomically. C. Singed nasal hairs Singed nasal hairs, stridor, wheezing, and dyspnea are also signs of inhalation injury. D. Respiratory rate of 24/min An increased respiratory rate does not indicate an inhalation injury.

A client with a burn injury is brought in to the urgent care clinic and the nurse begins an initial assessment. Which signs or symptoms from the client would the nurse attend to as highest priority? Select all that apply. A.The client has retractions in the chest with breathing B.The client complains of pain in the right arm C.The client has a 3-inch bandaged laceration on the shoulder D. The client has singed hairs around the mouth and nose E. The client has an oxygen saturation of 87 percent on room air

ANSWER A.D, E A. A client in a critical situation requires assessment that is prioritized to the highest priorities being first. In this case, as with many other emergency situations, the nurse would make assessing the client's airway, breathing, circulation, and cervical spine the highest priority over other minor injuries. The client has retractions in the chest with breathing B. While pain management is the responsibility of the nurse, it is a low priority compared to airway, breathing and circulation. C. The client has a 3-inch bandaged laceration on the shoulder The laceration is not described as bleeding, and it is bandaged, which means it has already been assessed at some point. This is not a priority for the nurse. The client has an oxygen saturation of 87 percent on room air D. The client has singed hairs around the mouth and nose A client in a critical situation requires assessment that is prioritized to the highest priorities being first. In this case, as with many other emergency situations, the nurse would make assessing the client's airway, breathing, circulation, and cervical spine the highest priority over other minor injuries. The client complains of pain in the right arm E. A client in a critical situation requires assessment that is prioritized to the highest priorities being first. In this case, as with many other emergency situations, the nurse would make assessing the client's airway, breathing, circulation, and cervical spine the highest priority over other minor injuries.

The client newly diagnosed with epilepsy is prescribed an anticonvulsant medication. Which information should the nurse tell the client? 1.The medication dosage will start low and gradually increase over a few weeks. 2.The dosage prescribed initially will be the dosage prescribed for the rest of your life. 3.The health-care provider will prescribe a loading dose and decrease dosage gradually. 4.The dose of medication will be adjusted monthly until a serum drug level is obtained.

ANSWER: 1 1. Anticonvulsant dosages usually start low and gradually increase over a period of weeks until the serum drug level is within therapeutic range or the seizures stop. 2. It is incorrect to state that the dosage prescribed will be the dosage for the rest of the client's life, but it is correct to state that the client will most likely be on the medication for the rest of his or her life. 3. This is incorrect information. The medication is started in low dosagesand gradually increased. 4. The dose of medication will be adjusted until a serum drug level is reached but it will be more frequently than monthly.

The client diagnosed with early-stage Parkinson's disease has been prescribed pramipexole (Mirapex), a dopamine agonist medication. Which side effect of this medication should the nurse teach the client?1. Daytime somnolence. 2. On-off effect. 3. Excessive salivation. 4. Pill rolling motion.

ANSWER: 1 1. Daytime somnolence is seen in about 22% of clients taking Mirapex. A few clients experience an overwhelming and irresistible sleepiness that comes on without warning. 2. The on-off effect with levodopa occurs when the therapeutic effects of the medication wear off. 3. Salivation is not a side effect of Mirapex. 4. Pill rolling motion is a symptom of PD, not a side effect of a medication.

Which statement indicates the scientific rationale for the combination drug carbidopa/levodopa (Sinemet) prescribed for Parkinson's disease? 1. The carbidopa delays the breakdown of the levodopa in the periphery so more dopamine gets to the brain. 2. The medication is less expensive when combined, so it is more affordable to clients on a fixed income. 3. The carbidopa breaks down in the periphery and causes vasoconstriction of the blood vessels. 4. Carbidopa increases the action of levodopa on the renal arteries, increasing renal perfusion.

ANSWER: 1 1. In Parkinson's disease there is a decreased amount of dopamine in the brain. Carbidopa delays the breakdown of levodopa (dopamine) in the periphery so that more of the levodopa crosses the blood-brain barrier and reaches the brain. 2. The expense of the medication is not the reason for the combination of the drugs. Sinemet comes in only one strength combination, which is a disadvantage of the medication. 3. Levodopa breaking down in the periphery is the reason that the medications are combined. 4. Carbidopa does not increase the action of levodopa; it delays the breakdown of the compound in the periphery.

The nurse is caring for a client newly diagnosed with Parkinson's disease who is receiving the anti-Parkinson's disease medication levodopa (L-dopa). Which inter- ventions should the nurse implement? Select all that apply. 1. Instruct the client to rise slowly from a seated or lying position. 2. Teach about on-off effects of the medication. 3. Discuss taking the medication with meals or snacks. 4. Tell the client that the sweat and urine may become darker. 5. Inform the client about having routine blood levels drawn.

ANSWER: 1,2,4 1. Initially levodopa can cause orthostatic hypotension. The client should be taught to rise slowly to prevent falls. 2. The client may experience an "on" effect of symptom control when the medication is effective and an "off " effect near the time for the next dose of medication. 3. Food can decrease the absorption of levodopa; administration with meals should be avoided, if possible. 4. Clients should be warned that darkening of the urine and sweat is a harmless side effect of this medication. 5. Routine blood levels of levodopa are not drawn.

Which statement made by the wife of a client diagnosed with Parkinson's disease (PD) indicates that teaching about the medication regimen has been effective? 1. "The medications will control all the symptoms of the PD if they are taken correctly." 2. "The medications provide symptom management, but the effects may not last." 3. "The medications will have to be taken for about 6 months and then stopped." 4. "The medications must be tapered off when he is better or he will have a relapse."

ANSWER: 2 1. All the symptoms may not be controlled even if the client adheres to a strict medication regimen. 2. PD is treated with medications and surgery. The medications have side effects and adverse effects, and the effectiveness of the medications may be reduced over time. 3. The client diagnosed with PD will need to take the medications for life unless surgery is performed and a significant improve- ment is achieved. 4. The medications do not have to be tapered when discontinued.

The client diagnosed with a stroke has been prescribed phenytoin (Dilantin), an anti- convulsant. Which statement explains the scientific rationale for prescribing this medication? 1. The client's stroke was caused by some damage to cerebral tissue. 2. The stroke caused damage to the brain tissue that could result in seizures. 3. Hemorrhagic strokes leave residual blood in the brain that causes seizures. 4. This medication can help the client with cognitive deficits think more clearly.

ANSWER: 2 1. Strokes cause damage to the cerebral tissue; the brain does not cause the damage to itself. 2. Stroke-caused loss of function in areas of the brain leads to a problem with nerve impulse transmission; this blocked transmission can initiate a seizure. 3. If the client survives a hemorrhagic stroke, the body will reabsorb the blood. There should not be any residual blood. 4. Anticonvulsants do not increase cognitive ability.

The client diagnosed with Parkinson's disease has been on long-term levodopa (L- dopa), an anti-Parkinson's disease drug. Which data supports the reason for placing the client on a "drug holiday"? 1. The medication is expensive and difficult to afford for clients on a fixed income. 2. The therapeutic effects of the drug have diminished and the adverse effects have increased. 3. The client has developed hypertension that is uncontrolled by medication. 4. An overdose is being taken and the medication needs to clear the system.

ANSWER: 2 1. The medication is not interrupted for this reason. 2. With long-term use of levodopa, the adverse effects tend to increase and the client may develop a drug tolerance where the therapeutic effects decrease. A short hiatus from the medication (10 days) may result in beneficial effects being achieved with lower doses. 3. Early in the treatment of PD with levodopa the client may have postural hypotension, but hypertension is not associated with levodopa. 4. An overdose is not being taken; the client's tolerance to the medication has changed.

The elderly client diagnosed with Parkinson's disease (PD) has been prescribed carbidopa/levodopa (Sinemet). Which data indicates the medication has been effective? 1. The client has cogwheel motion when swinging the arms. 2. The client does not display emotions when discussing the illness. 3. The client is able to walk upright without stumbling. 4. The client eats 30%-40% of meals within 1 hour.

ANSWER: 3 1. Cogwheel motion is a symptom of PD. Displaying cogwheel motion does not indicate the medication is effective. 2. Sinemet is a combination medication designed to delay the breakdown of levodopa (dopamine) in the periphery. A flat affect or no emotions would not indi- cate the medication is effective. 3. One of the symptoms of PD is a forward shuffling gait, so being able to walk upright without stumbling would indicate that the medication is effective. 4. The client should be encouraged to consume at least 50% of the meals provided. Meal times that last 1 hour are not encouraged because the client becomes fatigued and the food temperaturechanges. Hot foods become cold and cold foods become lukewarm. The client should be served frequent small meals each day.

The nurse is preparing to administer an oral medication to a client diagnosed with a stroke. Which intervention should the nurse implement first? 1. Crush all oral medications and place them in pudding. 2. Elevate the head 60 degrees. 3. Ask the client to swallow a drink of water. 4. Have suction equipment at the bedside.

ANSWER: 3 1. Some medications can be crushed and administered in pudding if the client has difficulty swallowing; however, enteric- coated or timed-release medications should not be crushed. The possibilityof difficulty in swallowing must be deter- mined first, before an oral medication is given. 2. The head of the bed should be elevated to 90 degrees when the client is swallowing food or medications. 3. The client's ability to swallow must be assessed before attempting to adminis- ter any oral medication. Water is the best fluid to use because it will not damage the lungs if aspirated. 4. Equipment is usually charged to the client. The nurse should first determine if suction equipment is needed prior to setting it up.

The nurse in the emergency department is preparing to administer the thrombolytic medication alteplase (Activase) to a client whose initial symptoms of a stroke began 2 hours ago. Which intervention should the nurse implement first? 1. Check the client's armband for allergies. 2. Hang the medication via IVPB and infuse over 90 minutes. 3. Check the results of the client's CT scan of the brain. 4. Teach the client that this medication dissolves clots.

ANSWER: 3 1. This is an important intervention, but it is not the first. 2. This is the correct procedure when hanging the medication, but it is not the first intervention. 3. There are three types of strokes: thrombotic, embolic, and hemorrhagic. The nurse must know that the client has not had a hemorrhagic stroke before hanging a medication thatdestroys clots. Administering a thrombolytic to a client who has had a hemorrhagic stroke can result in the client's death. In this question the steps in order would be three, one, two, and four. 4. Teaching the client can be done after the medication has been administered.

A client has sustained partial-thickness burns to his trunk and both lower extremities. Which IV fluid will the nurse initiate? 1. Albumin 2. 5% dextrose in water 3. Lactated ringer's solutio 4. 0.9% normal saline with 20 mEq potassiIun

ANSWER: 3 Lactated ringer's solution replaces lost sodium, and corrects metabolic acidosis, which commonly occurs following a burn. Albumin may be used as supportive therapy, but is not the primary fluid for replacement. Dextrose is not given to clients with burns during the first 24 hours as it may cause pseudodiabetes. The client is hyperkalemic due to the potassium shift from intracellular space to the plasma. Potassiumn would not be administered.

An infant has been brought into the emergency room for burns to their feet after being placed in a bath that was too hot. Which method should the nurse use to determine the percent of area burned for this infant? A. Lund Browder Chart B. Rule of Nines C. McBurney's Point Chart D. Rule of Three's

ANSWER: A A. Lund Browder Chart The Lund Browder chart is the chart used to determine percentage of area burned for pediatric clients. B. Rule of Nines This rule is utilized to determine the percentage of area burned in adults and would not be appropriate for use in an infant. C. McBurney's Point Chart This is not a burn tool. McBurney's Point is the area where pain may be located in appendicitis. D. Rule of Three's This is not a tool used for evaluating burns.

A client with a spinal cord injury has difficulty determining when the bladder needs emptied. The nurse teaches the client about tapping to stimulate voiding. How would the nurse describe tapping to this client? A. The area over the bladder is tapped to stimulate the bladder muscles B. The client bears down to increase pressure and then taps the base of the abdomen to release urine C. The client wears a device that acts as a tap or faucet to stop and start urine flow D. The client alternately taps the abdomen and the back to signal messages across the body to promote urination

ANSWER: A A. The area over the bladder is tapped to stimulate the bladder muscles A client with a spinal cord injury may be unable to control urine flow if there is little to no sensation in the bladder that tells the brain when it is time to empty the bladder. The nurse can teach the client techniques to stimulate urine flow. Tapping involves lightly tapping the area over the bladder with the fingertips to stimulate detrusor muscle contractions. B. The client bears down to increase pressure and then taps the base of the abdomen to release urine Tapping does not include bearing down, as this is a technique used for a client whose bladder has been affected by the spinal injury and has lost function. C. The client wears a device that acts as a tap or faucet to stop and start urine flow The technique of tapping does not include a device. D. The client alternately taps the abdomen and the back to signal messages across the body to promote urination Tapping does not include the back area.

The nurse caring for a 14-year-old with spina bifida knows that which of the following medications should be prescribed to help manage the neurogenic bladder. A. Oxybutynin B. Methylphenidate C. Docusate Sodium D. Ranitidine

ANSWER: A A. Oxybutynin Oxybutynin is given to decrease bladder spasms and increase bladder storage capacity. B. Docusate Sodium Docusate sodium is a stool softener that would be given to treat constipation. C. Ranitidine Ranitidine is given to treat gastroesophageal reflux. D. Methylphenidate Methylphenidate is a stimulant that is often used to help manage the symptoms of attention deficit hyperactive disorder (ADHD).

You are the nurse caring for a baby born an hour ago with myelomeningocele (Spina Bifida). When planning your nursing care you know that the baby is at risk for which of the following? Select all that apply. A. Gastrointestinal reflux B. Pneumonia C. Cardiogenic shock D. Infection E. Hypothermia

ANSWER: A, B A. Infection Children born with myelomeningocele are at increased risk for infection because of the exposed sac. B. Hypothermia Children born with myelomeningocele are at increased risk for hypothermia because the exposed sac loses heat. C, Cardiogenic shock Clients with myelomeningocele are not at increased risk for cardiogenic shock. Pneumonia D. Clients with myelomeningocele are not at increased risk for cpneumonia. E. Gastrointestinal reflux Clients with myelomeningocele are not at increased risk for gastrointestinal reflux.d bowel and bladder function.

The client has a spinal cord injury and is suffering from spinal shock. Which of the following is an expected symptom in spinal shock? A. Spasticity B. Bradycardia C. Increased visceral reflexes D. Hypertension

ANSWER: B A. Spasticity The opposite is seen in spinal shock, which is flaccid paralysis. B. Bradycardia A client with spinal shock is expected to be hypotensive, have bradycardia, decreased visceral reflexes and flaccid paralysis of skeletal muscles. C. Increased visceral reflexes Decreased visceral reflexes are seen in spinal shock. D. Hypertension Hypotension is seen in spinal shock.

The nurse is triaging a three-year-old that has come in with burns from a house fire. The nurse knows that the severity of the burns is primarily based on which of the following? Select all that apply. A. The amount of pain the child is experiencing. B. The percentage of total body surface area that is burned. C. The causative agent. D. The depth of the burn. E. The child's level of consciousness upon arrival to the ER.

ANSWER: B, D A. The amount of pain the child is experiencing. Deeper burns are less likely to cause pain due to damage to the nerves. B. The percentage of total body surface area that is burned. The percentage of the wound combined with the depth of the wound helps establish the severity. C. The causative agent. The agent causing the burn is not directly important for determining severity. D. The depth of the burn. Looking at the depth of injury is important for determining the severity of the injury. E. The child's level of consciousness upon arrival to the ER. While the level of consciousness is an important part of the nursing assessment, it is not used to classify the severity of the burn.

A client is brought into the emergency department after suffering from third-degree burns in an explosion. The client has burns on approximately 40 percent of his body. The nurse weighs the client and notes that he weighs 170 lbs. Calculate the volume of IV fluid this client must receive in the first 24 hours using the Parkland formula. A. 16000 mL B. 8000 mL C. 12000 mL D. 4000 mL

ANSWER: C C. 12000 mL The Parkland formula is a method of calculating the amount of fluid needed for fluid resuscitation after a burn injury. To use the Parkland formula, the nurse must know the weight of the patient in kg and the approximate size of the burn. The Parkland formula is as follows: Fluid requirement (mL) = (4 mL of crystalloid) × (% TBSA burned) × body weight (kg). 170 lbs = 77 kg. Therefore, 4 x 40 x 77 = 12,320 mL fluid. So 12,000 mL = 12 L fluid needed in the first 24 hours. The first half of the result should be given in the first 8 hours, with the second half of the result given in the following 16 hours.

The nurse is receiving report on a client with chemical burns over 70% of the body. The outgoing nurse states that the client's pain is a 7/10. The client has been averaging 80 ml/hr out of urine output and receiving 125 ml/hr 0.9% normal saline into a central venous catheter. The serum sodium is 133, K is 3.4, and Mag is 1.9. Vital signs are stable. The client is receiving antibiotics and is on a regular diet. What is the nurse's primary concern? A. Pain level B. Diet order C. Urinary output D. Magnesium level

ANSWER: C A. Pain level While the client's pain needs to be addressed, it is not the primary concern, The client WILL have pain. The more pressing concern is the fluid volume status. The IV fluid rate is the underlying problem that can be adjusted to help stabilize the fluid volume status. B. Diet order The client's regular diet is appropriate. Calories should not be restricted in a client with burns, because calories and protein are necessary for healing. C. Urinary output These client have a risk for dehydration, fluid volume overload, and third spacing, so optimizing fluid volume status is essential. Optimal fluid resuscitation is shown when the urinary output remains between 30-50 ml/hr. This client is putting out too much urine, and therefore receiving too much IV fluid. The IV rate should be adjusted. D. Magnesium level This is a normal magnesium level.

A nurse is assessing a 9-year-old burn injury client in the emergency department. Which of the following assessment findings is the most concerning and therefore the priority? A. Shivering B. Clothing burned into the skin C. Red, swollen throat D. Hypotension

ANSWER: C A. Shivering is a concern in burn injury clients due to lack of thermoregulation and increased heat loss. However, this does not take priority over an airway concern . B. Clothing burned into the skin This is concerning and will complicate initial wound care and evaluation, but is not a priority over an airway concern. C. Red, swollen throat When assessing level of importance, consider the ABC's. Swelling in the airway is most concerning. Any amount of swelling in the airway or presence of soot or burns is a red flag in a burn injury. The client may need an advanced airway to maintain patency as the swelling often gets worse before it gets better. Shivering D. Hypotension This is definitely a concern, especially for hypovolemia, which needs to be addressed. However, the concern for the client possibly losing a patent airway is a higher priority at this time. Once the airway is secured, the blood pressure can be addressed.

Which client diagnosed with Parkinson's disease should the nurse question administering the anticholinergic medication benztropine (Cogentin)? 1. The client diagnosed with congestive heart failure. 2. The client who has had a myocardial infarction. 3. The client diagnosed with glaucoma. 4. The client who is undergoing hip replacement surgery.

ANSWER:3 1. Anticholinergic medications are not contraindicated in clients diagnosedwith heart failure. 2. Anticholinergic medications are not contraindicated in clients who have hada myocardial infarction. 3. Anticholinergic medications block cholinergic receptors in the eye and may precipitate or aggravate glaucoma. 4. Anticholinergic medications are not contraindicated in clients undergoing surgery.

Which statement is an advantage of administering the catechol-O-methyltransferase (COMT) inhibitor entacapone (Comtan) to a client diagnosed with Parkinson's disease? 1. Comtan increases the vasodilating effect of levodopa. 2. Levodopa can be discontinued while the client is taking Comtan. 3. There are no side effects of the drug to interfere with treatment. 4. Comtan causes blood levels of levodopa to be smoother and more sustained.

ANSWER:4 1. Increased vasodilatation causes hypotension. This is not a reason to administer this drug. 2. Comtan is given in conjunction with levodopa to inhibit metabolism of levodopa in the intestines and peripheral tissues. There is no substitute for dopamine. Medications can increase the relative availability of the dopamine pres- ent in the body or can be a form of dopamine itself. 3. Many side effects may interfere with treatment, including hallucinations, postural hypotension, dyskinesias, and sleep disturbances. 4. Comtan increases the half-life of levodopa by 50-75%, thereby causing levodopa blood levels to be smoother and more sustained. This delays the "off " effects and prolongs the "on" effects of levodopa.

A baby has just been born with a myelomeningocele (Spina Bifida). The nurse knows that which of the following nursing interventions should be given top priority? A. Cover the sac with a dry, sterile dressing B. Cover the sac with a moist, sterile dressing C. Educate the parents on the child's need for immediate surgery D. Assess the baby for signs of neurogenic bladder

ANSWER:B A. Cover the sac with a dry, sterile dressing The sac needs to be covered with a moist sterile dressing to prevent it from drying out and reducing the risk for infection. B. Cover the sac with a moist, sterile dressing he sac needs to be covered with a moist sterile dressing to prevent it from drying out and reducing the risk for infection. C. Educate the parents on the child's need for immediate surgery While it will be important to educate the parents, protecting the sac should be given top priority. It needs to be covered with a moist sterile dressing to prevent it from drying out and reducing the risk for infection. D. Assess the baby for signs of neurogenic bladder The sac needs to be covered with a moist sterile dressing to prevent it from drying out and reducing the risk for infection.

The nurse is caring for a 2-day-old infant who is waiting to have surgery for a myelomeningocele repair (Spina Bifida). The nurse knows that the client needs to be in which of the following positions to protect the sac? A. Prone position with hips extended B. Supine position with hips flexed C. Supine position with hips extended D. Prone with hips flexed

Answer B A. Prone position with hips extended The infant should be put in the prone position with hips flexed to decrease any pressure being applied to the exposed sac. B Supine position with hips flexed The infant should be put in the prone position with hips flexed to decrease any pressure being applied to the exposed sac. C. Supine position with hips extended The infant should be put in the prone position with hips flexed to decrease any pressure being applied to the exposed sac. D. Prone with hips flexed The infant should be put in the prone position with hips flexed to decrease any pressure being applied to the exposed sac

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication 6. Place the client in a supine position with legs elevated

Answer: 1, 2, 4, 5 The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. Option C: A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta-blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

Answer: 1. An oral anticoagulant medication. Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge versus intravenous. Option B: Beta blockers slow the heart rate and lower the blood pressure. Option C: Anti-hyperuricemic medication is given to clients with gout. Option D: Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge.

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). 2. Emergent; the client is poorly oxygenated. 3. Normal 4. Significant; the client has alveolar hypoventilation.

Answer: 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Option B: Oxygenation is evaluated through PaO2 and oxygen saturation. Option D: Alveolar hypoventilation would be reflected in an increased PaCO2.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Reposition the client to avoid neck flexion 2. Administer 1 g Mannitol IV as ordered 3. Increase the ventilator's respiratory rate to 20 breaths/minute 4. Administer 100 mg of pentobarbital IV as ordered.

Answer: 1. Reposition the client to avoid neck flexion The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. Options B, C, and D: If nursing measures prove ineffective notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.

Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Slow, irregular respirations 2. Rapid, shallow respirations 3. Asymmetric chest expansion 4. Nasal flaring

Answer: 1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Options B, C, and D: Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). 1. Check for bladder distention 2. Raise the head of the bed 3. Contact the physician 4. Loosen tight clothing on the client 5. Administer an antihypertensive medication

Answer: 2, 4, 1, 3, 5. Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. 3. Dilantin should be mixed in dextrose in water before administration. 4. Dilantin should be administered through an IV catheter in the client's hand.

Answer: 2. Rapid Dilantin administration can cause cardiac arrhythmias. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Option A: Therapeutic drug levels range from 10 to 20 mg/ml. Option C: Dilantin shouldn't be mixed in solution for administration. However, because it's compatible with normal saline solution, it can be injected through an IV line containing normal saline. Option D: When given through an IV catheter hand, Dilantin may cause purple glove syndrome.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dl. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mmHg. 4. The presence of bronchogenic carcinoma.

Answer: 3. A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium. Option A: High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic. Option B: Bruit in the carotid artery would predispose a client to an embolic or ischemic stroke. Option D: Cancer is not a precursor to stroke.

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? 1. A client with a brain injury 2. A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke

Answer: 3. A client with a high cervical spine injury Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? 1. An interval when the client's speech is garbled 2. An interval when the client is alert but can't recall recent events 3. An interval when the client is oriented but then becomes somnolent 4. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

Answer: 3. An interval when the client is oriented but then becomes somnolent A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Option A: Garbled speech is known as dysarthria. Option B: An interval in which the client is alert but can't recall recent events is known as amnesia. Option D: Warning symptoms or auras typically occur before seizures.

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature

Answer: 3. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.

What is the expected outcome of thrombolytic drug therapy? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage

Answer: 3. Dissolved emboli. Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion.

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. Give the client a warming blanket 2. Administer low-dose barbiturate 3. Encourage the client to hyperventilate 4. Restrict fluids

Answer: 3. Encourage the client to hyperventilate Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. Option A: A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. Option B: High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Option D: Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? 1. Assess full ROM to determine extent of injuries 2. Call for an immediate chest x-ray 3. Immobilize the client's head and neck 4. Open the airway with the head-tilt-chin-lift maneuver

Answer: 3. Immobilize the client's head and neck m All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. Option A: ROM would be contraindicated at this time. Option B: There is no indication that the client needs a chest x-ray. Option D: In addition, the head-tilt-chin-lift maneuver wouldn't be used until the cervical spine injury is ruled out.

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? 1. Acetazolamide (Diamox) 2. Furosemide (Lasix) 3. Methylprednisolone (Solu-Medrol) 4. Sodium bicarbonate

Answer: 3. Methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance.

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism

Answer: 3. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Option A: Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Option B: Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Option D: Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? 1. Bladder distension 2. Neurological deficit 3. Pulse ox readings 4. The client's feelings about the injury

Answer: 3. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Options A, B, and D: Although the other options would be necessary at a later time, observation for respiratory failure is the priority.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

Answer: 3. Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Option A: rt-PA is contraindicated. Options B and D: Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1. Current medications. 2. Complete physical and history. 3. Time of onset of current stroke. 4. Upcoming surgical procedures.

Answer: 3. Time of onset of current stroke. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. Option A: Current medications are relevant, but the onset of current stroke takes priority. Option B: A complete history is not possible in emergency care. Option D: Upcoming surgical procedures will need to be delay if t-PA is administered.

Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet 3. Supination of arms, dorsiflexion of feet 4. Back arched; rigid extension of all four extremities.

Answer: 4. Back arched; rigid extension of all four extremities. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by the arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Option A: Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? 1. Headache 2. Lumbar spinal cord injury 3. Neurogenic shock 4. Noxious stimuli

Answer: 4. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decubitus ulcer, may cause autonomic dysreflexia. Option A: A headache is a symptom of autonomic dysreflexia, not a cause. Option B: Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Option C: Neurogenic shock isn't a cause of dysreflexia.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? 1. Place the client flat in bed 2. Assess patency of the indwelling urinary catheter 3. Give one SL nitroglycerin tablet 4. Raise the head of the bed immediately to 90 degrees

Answer: 4. Raise the head of the bed immediately to 90 degrees Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Option A: Putting the client flat will cause the blood pressure to increase even more. Option B: The indwelling urinary catheter should be assessed immediately after the HOB is raised. Option C: Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.

A client with a C6 spinal injury would most likely have which of the following symptoms? 1. Aphasia 2. Hemiparesis 3. Paraplegia 4. Tetraplegia

Answer: 4. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Option C: Paraplegia occurs as a result of injury to the thoracic cord and below.

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1. Absent corneal reflex 2. Decerebrate posturing 3. Movement of only the right or left half of the body 4. The need for mechanical ventilation

Answer: 4. The need for mechanical ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. Options A, B, and C: Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.

The nurse is caring for a child who was in a house fire. The nurse notes that the hairs on the child's face are singed. Based on this assessment finding, the nurse monitors the client closely for which of the following complications that may occur following burn injuries? A. Sepsis B. Electrolyte imbalances C. Hypothermia D. Inhalation injury

CORRECT D A. Sepsis While a child with burns is at risk for sepsis, the singed hairs should make the nurse more concerned about inhalation injury. B. Electrolyte imbalances While the child may have electrolyte imbalances after a severe burn, it is not the most appropriate concern based on the assessment findings. C. Hypothermia While a child with burns is at risk for hypothermia, the singed hairs should make the nurse more concerned about potential inhalation injury. D. Inhalation injury The singed hair on the face indicates that the child's face was exposed to extreme heat and their airway may be damaged.