MS f#2
A patient is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer? Canagliflozin Propranolol A proton pump inhibitor Regular insulin
A proton pump inhibitor
A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose: 648 mg/dLpH: 6.88PaCO2: 20 mm HgPaO2: 95 mm HgHCO3¯: undetectableAnion gap: >31Na+: 127 mEq/LK+: 3.5 mEq/LCreatinine: 1.8 mg/dL After the patient's airway and ventilation have been established, the next priority for this patient is: IV push administration of 1 amp of sodium bicarbonate. administration of 20 mEq KCl in 100 mL. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. administration of a 1-L normal saline fluid bolus.
administration of a 1-L normal saline fluid bolus.
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. Hypothermia Diaphoresis Tachycardia Tachypnea Hypotension Venous pooling
Hypothermia Tachypnea Hypotension Venous pooling
Which of the following statements is true about the medical management of diabetic ketoacidosis? Sodium bicarbonate is a first-line medication for treatment. The degree of acidosis is assessed through continuous pulse oximetry. Serum lactate levels are used to guide insulin administration. Volume replacement and insulin infusion often correct the acidosis.
Volume replacement and insulin infusion often correct the acidosis.
Nursing care for a client in Addisonian crisis should include which intervention? Placing the client in a private room Offering extra blankets and raising the heat in the room to keep the client warm Encouraging independence with activities of daily living (ADLs) Allowing ambulation as tolerated
Placing the client in a private room
Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? Computed tomography (CT) Transcranial Doppler Cerebral angiography Magnetic resonance imaging (MRI)
Transcranial Doppler
Acute adrenal crisis is caused by deficiency of corticosteroids. high doses of corticosteroids. acute renal failure. overdose of testosterone.
deficiency of corticosteroids.
Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? Negative ketones in the urine pH 7.24 Normal anion gap Blood glucose >1000 mg/dL
pH 7.24
Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? pH 7.24 Normal anion gap Negative ketones in the urine Blood glucose >1000 mg/dL
pH 7.24
Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? Serum sodium 115 mEq/L Serum sodium 152 mEq/L Fasting blood glucose 156 mg/dL Serum potassium 5.8 mEq/L
Serum sodium 115 mEq/L
Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) Pituitary tumors Sickle cell disease Medications Heredity Meningitis
Sickle cell disease Medications Heredity
In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? When the blood sugar reaches 150 mg/dL When the blood glucose reaches 250 mg/dL When the blood sugar reaches 70 mg/dL Never; normal saline is the only appropriate solution in diabetes management
When the blood glucose reaches 250 mg/dL
A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain? idiopathic allodynia hyperalgesia nociceptive
allodynia
A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) pH: 7.23 PaCO2: 37 mm Hg HCO3—: 10 mEq/L Blood glucose: 43 mg/dL Blood glucose: 524 mg/dL
pH: 7.23 HCO3—: 10 mEq/L Blood glucose: 524 mg/dL
The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing syndrome of inappropriate secretion of antidiuretic hormone. diabetic ketoacidosis. hyperosmolar hyperglycemic syndrome. diabetes insipidus.
diabetes insipidus.
The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first? Acetaminophen (Tylenol) 650 mg per rectum Blood cultures (2 specimens) for temperature >101°F 500 mL albumin infusion intravenously Decadron 20 mg intravenous push every 4 hours
500 mL albumin infusion intravenously
What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) Exposure to influenza Altered sleep/rest patterns Eating disorder High levels of stress Lack of financial resources
Altered sleep/rest patterns Eating disorder High levels of stress Lack of financial resources
The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action? Apply a small nasal drip pad. Monitor airway patency. Insert bilateral ear plugs. Maintain neutral head position.
Apply a small nasal drip pad.
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? Notify the provider of the patient's blood pressure. Encourage the patient to take slow, deep breaths. Assess for a kinked urinary catheter and assess for bowel impaction. Administer acetaminophen as ordered for the headache.
Assess for a kinked urinary catheter and assess for bowel impaction.
A patient whose laboratory studies indicates a prolactin level of 200 ng/mL is assessed for a pituitary tumor. During the physical exam, the nurse practitioner notices a number of signs and/or symptoms suggestive of this condition. Which of the following is the most common indicator of a pituitary tumor? Galactorrhea Inappropriate responses to stimuli Tremors and palpitations Headaches and visual disturbances
Galactorrhea
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? Both pressures are high. ICP is high; CPP is low. Both pressures are low. ICP is high; CPP is normal.
ICP is high; CPP is normal.
The nurse is caring for a patient admitted with bacterial meningitis. Vital signsassessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5°F. What is the priority nursing action? Implement seizure precautions. Maintain bed rest at all times. Keep lights dim at all times. Elevate the head of the bed 30 degrees.
Implement seizure precautions.
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? Decreased cerebral blood volume due to vessel constriction No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) Altered cerebral spinal fluid production and reabsorption Increased cerebral blood volume due to vessel dilation
Increased cerebral blood volume due to vessel dilation
The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? Decreased cerebral blood volume due to vessel constriction No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) Increased cerebral blood volume due to vessel dilation Altered cerebral spinal fluid production and reabsorption
Increased cerebral blood volume due to vessel dilation
A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? A decreased TSH level No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test An increase in the TSH level after 30 minutes during the TSH stimulation test Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay
No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? Propofol (Diprivan) Midazolam (Versed) Phenobarbital Lorazepam (Ativan)
Propofol (Diprivan)
The greatest risk of seizures for clients with brain tumors occurs in those who have tumors in which regions of the brain? Select all that apply. Temporal Parietal Occipital Frontal Brain stem
Temporal Parietal Frontal
The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? The patient is experiencing an allergic reaction. The patient most likely has an elevated temperature. The vital signs are normal for this patient. The patient is developing neurogenic shock.
The patient is developing neurogenic shock.
The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing syndrome of inappropriate secretion of antidiuretic hormone. hyperosmolar hyperglycemic syndrome. diabetic ketoacidosis. diabetes insipidus.
diabetes insipidus.
A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of: diabetic ketoacidosis. hyperosmolar, hyperglycemic state. adrenal insufficiency. hypoglycemia.
diabetic ketoacidosis.
A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find: loss of motor power and sensation in the upper extremities. preservation of a sense of touch below the level of the lesion. loss of the sensation of pain and temperature on the side opposite the injury.
loss of motor power and sensation in the upper extremities.
While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? 12 to 24 hours 18 to 36 hours 48 to 72 hours 6 to 8 hours
18 to 36 hours
The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the provider prescriptions, which order is of the highest priority? 500 mL albumin intravenous infusion Dilantin 50 mg intravenous push Decadron 10 mg intravenous push Lasix 20 mg intravenous push as needed
500 mL albumin intravenous infusion
Which patient being cared for in the emergency department should the charge nurse evaluate first? A patient with a complete spinal cord injury at the C5 dermatome level An ischemic stroke patient with a blood pressure of 190/100 mm Hg A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula An alert patient with a subdural bleed who is complaining of a headache
A patient with a complete spinal cord injury at the C5 dermatome level
After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? A patient with meningitis complaining of photophobia A mechanically ventilated patient with a GCS of 6 A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F A patient with bacterial meningitis on droplet precautions
A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) Water deprivation ADH deficiency ADH replacement therapy ADH excess ADH insensitivity
ADH deficiency ADH insensitivity
The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? Administer over 2 minutes. Administer over 20 to 30 minutes. Administer via central line. Mix medication with 0.9% normal saline.
Administer over 20 to 30 minutes.
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections An 18-year-old college student with type 1 diabetes who exercises excessively A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply. Apnea No brain waves Coma Absence of brainstem reflexes
Apnea Coma Absence of brainstem reflexes
client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. Autonomic dysreflexia Orthostatic hypotension Salt-wasting syndrome DVT Increased ICP
Autonomic dysreflexia Orthostatic hypotension DVT
The nurse is preparing to administer a routine dose of phenytoin. The provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? Administer with 0.9% normal saline intravenous. Assess cardiac rhythm. Administer over 2 minutes. Contact the provider.
Contact the provider.
The nurse is caring for a client who is currently under medical investigation for a pituitary adenoma. The nurse anticipates the client will likely report which symptoms that are consistent with this type of brain tumor? Select all that apply. Seizures Disturbed sleep Impairment of visual field Polyuria Polydipsia
Disturbed sleep Impairment of visual field Polyuria Polydipsia
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? Epidural Intracerebral Subdural Diffuse axonal
Epidural
In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.) Eye movement in the opposite direction as the head when turned indicates an intact reflex. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. Presence of cervical injuries is a contraindication to the assessment of this reflex. Eye movement in the same direction as the head when turned indicates an intact reflex. Doll's eyes present indicate brainstem activity. Doll's eyes absent indicate a disruption in normal brainstem processing.
Eye movement in the opposite direction as the head when turned indicates an intact reflex. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. Presence of cervical injuries is a contraindication to the assessment of this reflex. Doll's eyes present indicate brainstem activity. Doll's eyes absent indicate a disruption in normal brainstem processing.
Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? Fluid volume deficient Activity intolerance Impaired nutrition, more than body requirements Hyperthermia
Fluid volume deficient
Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? Activity intolerance Impaired nutrition, more than body requirements Fluid volume deficient Hyperthermia
Fluid volume deficient
A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? His autoimmune disease will go into remission. He will go into thyroid storm. He will go into adrenal crisis. Nothing; it is appropriate to stop the medication for 3 days.
He will go into adrenal crisis.
In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? Lower serum glucose, lower osmolality, and milder ketosis Lower serum glucose, lower osmolality, and greater ketosis Higher serum glucose, higher osmolality, and no ketosis Higher serum glucose, higher osmolality, and greater ketosis
Higher serum glucose, higher osmolality, and no ketosis
The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? Tachycardia Hypertension Hyperthermia Bradypnea
Hyperthermia
Thyroid storm is a severe form of hyperthyroidism that can be fatal if not treated. Medical management includes pharmacotherapy. Which of the following drugs have proved helpful? Select all that apply. Iodine Methimazole Acetaminophen Salicylates Hydrocortisone
Iodine Methimazole Acetaminophen Hydrocortisone
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? It refers to the permanent deficits seen after the rehabilitation process. It refers to the difficulties suffered by the client and family related to the changes in the client. It results from initial damage to the brain from the traumatic event. It results from inadequate delivery of nutrients and oxygen to the cells.
It results from inadequate delivery of nutrients and oxygen to the cells.
The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) Restrain affected limb to prevent injury. Maintain CO2 level at 50 mm Hg. Maintain MAP less than 130 mm Hg. Prepare for thrombolytic administration. Make frequent neurological assessments.
Maintain MAP less than 130 mm Hg. Make frequent neurological assessments.
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first? Ancef 1 g intravenous Mannitol 1 g intravenous Seizure precautions Portable chest x-ray
Mannitol 1 g intravenous
The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? Pad all bony prominences. Maintain body temperature. Monitor blood pressure. Use proper hand washing.
Monitor blood pressure.
Which of the following symptoms would a patient exhibit with hyperthyroidism? Correct! None of the above Decreased bowl movements Intolerance to cold Slow heart rate
None of the above
The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? Notify the provider immediately. Continue to monitor the patient. Stimulate the patient hourly. Elevate the head of the bed.
Notify the provider immediately.
Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.) Open skull fracture Mean arterial pressure 48 mm Hg Elevated serum blood alcohol level Respiratory rate of 10 breaths/min Nonreactive pupils
Open skull fracture Mean arterial pressure 48 mm Hg Respiratory rate of 10 breaths/min Nonreactive pupils
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? Ensure adequate periods of rest between nursing interventions. Insert an oral airway and monitor respiratory rate and depth. Maintain neutral head alignment and avoid extreme hip flexion. Reduce ambient room temperature and administer antipyretics.
Reduce ambient room temperature and administer antipyretics.
A nurse is caring for a client with suspected hyperparathyroidism. Which condition may contribute to hyperparathyroidism? Thyroidectomy Renal failure Decreased serum calcium level Steroid use
Renal failure
The nurse is caring for a client postoperatively from a spinal tumor resection. The nurse assesses that the client has partial paralysis. What anticipated problems should the nurse include in the client's care plan? Select all that apply. Risk for powerlessness Risk for impaired physical mobility Risk for sexual dysfunction Risk for injury Risk for knowledge deficit
Risk for powerlessness Risk for impaired physical mobility Risk for injury Risk for knowledge deficit
Which of the following are the immediate complications of spinal cord injury? Paraplegia Tetraplegia Spinal shock Autonomic dysreflexia Respiratory arrest
Spinal shock Respiratory arrest
The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? The patient is withdrawing to stimulation. The patient is exhibiting extension posturing. The patient is exhibiting flexion posturing. The patient is exhibiting purposeful movement.
The patient is exhibiting purposeful movement.
Which of the following statements to the Type 2 Diabetic patient by the nurse is correct? Check your blood sugar only after meals. Minimize physical activity to prevent fatigue. Try to wear closed toe shoes whenever ambulating. Eat less fruits and vegetables and more grains.
Try to wear closed toe shoes whenever ambulating.
What nursing intervention will best help the client with Huntington disease to increase nutrition? Select all that apply. Use Relaxation techniques Maintain a pureed diet Increase high carbohydrate foods Take phenothiazine prior to meals Eliminate foods high in fat
Use Relaxation techniques Take phenothiazine prior to meals
A patient is admitted to the oncology unit with a small-cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). myxedema coma. diabetes insipidus. adrenal crisis.
syndrome of inappropriate secretion of antidiuretic hormone (SIADH).
The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) 29-year-old female who is undergoing evaluation for pheochromocytoma 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 18-year-old male who has undergone surgical correction of a fractured femur 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD) 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN)
29-year-old female who is undergoing evaluation for pheochromocytoma 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD) 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN)
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? Insert an oral airway and monitor respiratory rate and depth. Maintain neutral head alignment and avoid extreme hip flexion. Reduce ambient room temperature and administer antipyretics. Ensure adequate periods of rest between nursing interventions.
Reduce ambient room temperature and administer antipyretics.
In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.) Doll's eyes present indicate brainstem activity. Doll's eyes absent indicate a disruption in normal brainstem processing. Eye movement in the opposite direction as the head when turned indicates an intact reflex. Eye movement in the same direction as the head when turned indicates an intact reflex. Presence of cervical injuries is a contraindication to the assessment of this reflex. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex.
Doll's eyes present indicate brainstem activity. Doll's eyes absent indicate a disruption in normal brainstem processing. Eye movement in the opposite direction as the head when turned indicates an intact reflex. Presence of cervical injuries is a contraindication to the assessment of this reflex. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex.
An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual's priority action? Eat something with 15 g of simple carbohydrates. Take another dose of the oral agent. Go to the first-aid station to have glucose checked. Drink additional water to prevent dehydration.
Eat something with 15 g of simple carbohydrates.
A client with a brain tumor is experiencing changes in cognition that require the nurse to reorient the client frequently. When performing this task, which devices would be appropriate for the nurse to use? Select all that apply. Picture of the client's family Client's clothing Calendar Common words Clock
Picture of the client's family Client's clothing Calendar Clock
The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? ICP of 10 mm Hg GCS score of 5 CVP of 2 mm Hg CPP of 70 mm Hg
CVP of 2 mm Hg
Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following are causes of secondary brain injury? Select all that apply. Cerebral edema Infection Ischemia Seizures Hyperthermia
Cerebral edema Infection Ischemia Seizures Hyperthermia
The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) Manually flushing the device "prn" Use of a heparin flush solution Use of a pressurized flush system Zero referencing the transducer system Recording ICP as a "mean" value
Zero referencing the transducer system Recording ICP as a "mean" value
A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with: hyperthyroidism. hypoglycemia. neuropathy. depression.
depression.
The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? Administer via central line. Administer over 20 to 30 minutes. Administer over 2 minutes. Mix medication with 0.9% normal saline.
Administer over 20 to 30 minutes.
