NP4 Test 2 Study Guide

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a.triggers that lead to facial pain. b.visual problems caused by ptosis. c.poor appetite caused by a loss of taste. d.weakness on the affected side of the face.

a.triggers that lead to facial pain. The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

A person going through the sympathetic response will show which bodily action? a. constriction of pupils b. peripheral vasoconstriction c. contraction of bladder d. stimulation of the digestive system

b. peripheral vasoconstriction This answer is correct since peripheral vasoconstriction is when blood flow is diverted to muscles needed during a fight or flight response. The overall effect of vasoconstriction is to increase cardiac output. Enhanced sympathetic activity such as vasoconstriction is particularly important during the fight or flight response. The other answers are all expamples of parasympathetic responses

The nurse notes documentation that a client who experienced a brain attack (stroke) has Broca's aphasia. The nurse expects to note which characteristics of this type of aphasia in the client? Select all that apply. A.Able to speak in long sentences that have no meaning. B.Able to speak in short sentences, often omitting small words. C.The client has difficulty understanding speech. D.May be extremely limited in ability to speak orcomprehend language. E.The client is often aware of difficulties with speech and becomes easily frustrated.

B & E Rationale:Broca's (nonfluent) aphasia: able to comprehend speech and speak in short sentences, often omitting small words. Takes a great deal of effort to speak and client often becomes frustrated.

A nurse manager has to deal with a difficult physician who is demeaning as well as demanding. The nurse manager has learned that assertiveness, accuracy, and honesty are attributes of which skill necessary for collaborative care? A.Networking B.Shared governance C.Critical thinking D.Communication

D.Communication Rationale:Assertiveness, accuracy, and honesty refer to communication skills.

Which statement is correct about the amyotrophic lateral sclerosis (ALS)? A.Successful treatment consists of large doses of intravenous steroids. B.There is a higher incidence in females between the ages of 15 and 50. C.Life expectancy after diagnosis is approximately 20 years. D.Death frequently occurs from decreased respiratory function

D.Death frequently occurs from decreased respiratory function Rationale: IN ALS, death usually results from respiratory infection secondary to compromised respiratory function. Males get it more frequently than females. There is no successful treatment and life expectancy is 2 to 6 years post diagnosis.

Following surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? A.Elevate the head of the patient's bed to 45 degrees. B.Administer IV diuretic medications. C.Document the CVP and continue to monitor. D.Increase the IV fluid infusion per protocol.

D.Increase the IV fluid infusion per protocol. Rationale: A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP

The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client? 1. Deficient fluid volume related to acute blood loss 2. Risk for aspiration related to acute bleeding in the GI tract 3. Risk for infection related to acute disease process and medications 4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased metabolism

1. Deficient fluid volume related to acute blood loss Rationale: The priority problem for the client with acute gastrointestinal bleeding among these options is deficient fluid volume related to acute blood less. This state can result in decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration and infection, but these are not actual problems at this point in time.

Several hours following a surgical repair of an abdominal aortic aneurysm, the patient develops hypoactive bowel sounds, increased abdominal distention and nausea. The nurse recognizes that these findings most likely indicate development of which complication? A.Intestinal perforation B.Hypovolemia C.Infection D.Paralytic ileus

D.Paralytic ileus Rationale:Due to decreased perfusion to gut, paralytic ileus is a potential complication following AAA surgery. Decreased to absent bowel sounds, especially in conjunction with abdominal distention and nausea are indicative of paralytic ileus and should be addressed immediately.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the primary health care provider (PHCP).

1. Slow the IV infusion. Rationale: The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's breathing, if necessary. The nurse also notifies the PHCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2,3,5 Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

A 3-year-old boy is brought to the emergency department by his parents after he was noted to be "acting differently than normal" a few hours ago while he was being cared for by his grandmother. When she went to take her evening medication, the grandmother noted that her pill container had been opened and some pills were missing. The parents state that the grandmother has a heart condition. The nurse conducts a history and assessment and notes the findings below. Select all the history and assessment findings that would require the nurse to follow-up immediately. Select all that apply. A. The child has nausea and vomiting that began an hour ago B. Temperature is 36.8°C (98.4°F). C. Pulse is 48 beats/min D. Respiration rate is 20 breaths/min E. Heart rate is irregular F. Child is irritable

A, C, E, F

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3,4,5,6 Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse suspects increased intracranial pressure in the patient exhibiting which symptoms? Select all that apply. A.Widened pulse pressure B.Vomiting C.Restlessness D.Abnormal posturing E.Pupillary changes

ALL Rationale: First sign of increased ICP is decline in LOC. Other CM: restlessness, irritability, confusion, HA, N/V; pupillary changes, abnormal posturing, Cushing's triad.

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F (38.1° C) orally. Which action should the nurse take? 1. Begin the transfusion as prescribed. 2. Administer an antihistamine and begin the transfusion. 3. Administer 2 tablets of acetaminophen and begin the transfusion. 4. Delay hanging the blood and notify the primary health care provider (PHCP).

4. Delay hanging the blood and notify the primary health care provider (PHCP). Rationale: If the client has a temperature higher than 100° F (37.8° C), the unit of blood should not be hung until the primary PHCP is notified and has the opportunity to give further prescriptions. The PHCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCP's prescription to administer medications to the client.

When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? A.Begin continuous cardiac monitoring. B.Insert an indwelling urinary catheter. C.Assist with endotracheal intubation. D.Obtain an order to restrain the patient. E.Prepare to give sympathomimetic drugs

A, B, C Rationale:Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated.

A patient with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take (select all that apply)? a.Prepare to administer atropine IV. b.Obtain baseline body temperature. c.Prepare for intubation and mechanical ventilation. d.Administer large volumes of lactated Ringers solution. e.Administer high-flow oxygen(100%) by non-rebreather mask

A, B, C, E All of the actions are appropriate except to give large volumes of lactated Ringers solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringers solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate

Upon assessmentof a patient with a SCI at T5, the patient complains of a headache and the blood pressure is found to be 178/94mmHg. The nurse recognizes that the patient may be experiencing a life-threatening complication and completes which priority intervention(s)? Select all that apply. A.Loosen tight clothing. B.Check the patient for fecal impaction. C.Check the Foley catheter for kinks or obstructions. D.Place a fan on the patient to cool the patient. E.Elevate the head of bed (HOB).

A, B, C, E Rationale: The patient is experiencing autonomic dysreflexia. Place the client in sitting position, notify the MD, loosen tight clothing, assess and treat cause, check catheter for kinks, if no Foley present, check for bladder distention, check for fecal impaction, check room temp to ensure not too hot or cool, check for wrinkled bed linens/something under patient.

Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)? A.Stability of the patient B.Institutional policies C.State nurse practice act D.LPN/LVN teaching abilities E.Experience of the LPN/LVN

A, B, C, E Rationale:The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, LPN/LVN scope of practice includes caring for patients who are stable, while registered nurses should provide most of the care for unstable patients. Since LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process.

The emergency room nurse is caring for a patient brought in by ambulance. Upon assessment, the nurse finds the patient to be hypotensive and tachycardic, with wheezing and noted respiratory distress. The patient states that he was stung by a bee while working in the yard.The nurseanticipates performing which priority interventions? Select all that apply. A.Administer diphenhydramine to decrease immuneresponse. B.Administer intravenous crystalloid solutions. C.Administer digoxin (Lanoxin) to increase cardiac contractility. D.Administer glucocorticoids to reduce inflammatory response. E.Obtain stat blood cultures.

A, B, D Rationale: The patient is experiencing an anaphylactic reaction. IV fluids, corticosteroids, diphenhydramine, epinephrine, famotidine, and albuterol are common treatment options. Digoxin is mor apt to be utilized in a cardiogenic shock. Blood culture wouldbe obtained if an infection were present, such as in septic shock. Vasodilators would be needed for hemodynamic instability, such as in septic shock.

Patients with which of the following chronic neurological conditions experience increased risk of respiratory complications. Select all that apply. A.Amyotrophic Lateral Sclerosis B.Multiple Sclerosis C.Myasthenia Gravis D.Guillain-Barre E.Parkinson's Disease F.Huntington's Disease

A, C, D Rationale: As a result of muscle weakness the vital capacity is reduced, leading to increased risks of respiratory complications; impaired swallowing can also lead to aspiration.

The nurse is assessing a 38 year old client diagnosed with multiple sclerosis. The nurse would expect to find which of the following symptoms? (Select all that apply). A.Blurred or double vision B.Pill rolling tremors C.Spasticity of the muscles D.Fatigue and weakness E.Eyelid drooping

A, C, D Rationale:The signs and symptoms that accompany MS are varied but include: fatigue and weakness, blurred or double vision, and spastic muscles. Pill rolling tremors and eyelid drooping are not associated with MS

The nurse is told in report that an assigned client suffered a left cerebral hemisphere brain attack (stroke). The nurse expects to note which manifestations on assessment of the client? Select all that apply. A.impaired speech/language aphasias B.spatial-perceptual deficits C.impaired right/left discrimination D.impaired time conceptsE.right-sided neglect

A, C, E Rationale: Clinical manifestations of left-side stroke: paralyzed right side; impaired speech/language aphasias; impaired right/left discrimination; slow, performance; cautious; aware of deficits; depression; anxiety; impaired comprehension related to language and math

A nurse is managing the care of a client who was just admitted with a diagnosis of DKA. The nurse will anticipate receiving which of the following orders? Select all that apply. A.Closely monitor electrolytes. B.Administer regular insulin subcutaneously per sliding scale. C.Place the client on a potassium-restricted diet. D.Administer IV 0.9% NaCl at 1,000 mL/hr until urine output is 30 -60 mL/hr. E.Check vital signs and neurological status every 15 minutes until stable.

A, D, E Rationale: Initial interventions for the client in DKA include: establishing an IV, beginning fluid resuscitation with 0.45% or 0.9% NaCl at 1000ml/hr to restore urine output to 30-60 mL/hr; continuous regular insulin drp 0.1 U/kg/hr, ongoing monitoring of VS, LOC, cardiac rhythm, O2 sats, and UO. Glucagon is utilized in hypoglycemia. Regular subcutaneous insulin would not be appropriate, IV is needed in this situation. A potassium-restricted diet is not appropriate, although electrolytes should be closely monitored and pts with hypokalemia should be given potassium to correct the imbalance. Cardiac monitoring should also be implemented

A client is diagnosed with an epidural hematoma. Choose all of the nursing interventions that the RN should implement with this client. 1. HOB up 30 degrees. 2. Daily stool softeners. 3. Administer O2 to keep pulse oximetry reading > 90%. 4. Deep nasal suction every 2 hours. 5. Incentive spirometry every 2 hours. A.1, 2, 3 B.2, 3, 5 C.1, 2, 4 D.1, 4, 5

A.1, 2, 3 Rationale:(4, 5 are not appropriate) Deep nasal suctioning and Incentive Spirometry would increase intracranial pressure. The other options would maintain or decrease ICP.

The patient in septic shock has a BP of 90/54, HR of 125, CVP of 3, and a urine output of 20 mL/hr for the past 3 hours. The patient weights115kg. The nurse will question which of the following orders? A.Administer furosemide 40 mg IV. B.Increase the infusion of normal saline to 125mL/hr. C.Administer hydrocortisone 100 mg IV. D.Titrate Levophed to keep mean arterial pressure 65 mm Hg or greater

A.Administer furosemide 40 mg IV. Rationale:Assessment findings indicate that the patient is hypovolemic. Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate.

A client found unresponsive, hypotensive, and tachypneic with a body temperature of 106 degrees F is brought to the emergency department. What is the priority nursing action for this client? A.Removing all clothing and placing ice packs in the axilla and groin. B.submerge patient in ice bath C.Take an oral temperature and blood pressure. D.Contacting next of kin for permission to treat.

A.Removing all clothing and placing ice packs in the axilla and groin. Rationale:Reducing the temperature is the priority action in this situation. The other options may be instituted but are not the priority.

Which assessment finding is most important for the nurse to report to the health care providerwhen caring for a patient in septic shock? A.Skin cool and clammy B.Heart rate 122beats/minute C.Oxygen saturation 90% D.Blood pressure (BP) 92/50mm Hg

A.Skin cool and clammy Rationale:Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient's status

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? A.The patient has difficulty speaking. B.The pulse rate is 102 beats/min. C.The blood pressure is 144/86 mm Hg. D.There are fine crackles at the lung bases.

A.The patient has difficulty speaking. Rationale:Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths

Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? A.The patient's central venous pressure is 2. B.The patient is receiving low dose dopamine (Intropin). C.The patient's blood pressure is 80/44. D.The patient is in sinus tachycardia.

A.The patient's central venous pressure is 2. Rationale: Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? A.The patient's serum creatinine level is elevated. B.The patient's extremities are cool and pulses are weak. C.The patient has bilateral crackles throughout lung fields. D.The patient complains of intermittent chest pressure.

A.The patient's serum creatinine level is elevated. Rationale:The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patient's diagnosis of cardiogenic shock.

A 72-year old man is hospitalized for an aortic dissection of an abdominal aorta that stabilizes with treatment. The RN develops a teaching plan for the client's discharge home that includes an emphasis on? A.Using prescribed anti-hypertensive medications to keep B/P as low as possible to maintain vital perfusion. B.Performing leg exercises to increase peripheral collateral circulation. C.Using NSAIDs as often as needed. D.Daily home monitoring of pulse for signs of increased bleeding.

A.Using prescribed anti-hypertensive medications to keep B/P as low as possible to maintain vital perfusion. Rationale: HTN that is untreated can lead to rupture and decreased tissue perfusion, and eventually death

While carrying for a patient newly diagnosedwith Guillain-Barré, the nurse understands which assessment to be the top priority A.frequent assessment of respiratory function. B.monitoring vital signs C.level of consciousness D.evaluating sensory and motor function of the extremities

A.frequent assessment of respiratory function. Rationale: Assessment of the patient is the most important aspect of nursing care during the acute phase. The nurse must monitor the ascending paralysis; assess respiratory function; monitor ABG's, and assess gag and swallowing reflexes. It is imperative to constantly assess respiratory function, as the paralysis may reach the diaphragm, in which case the patient will no longer be able to breathe.

A nurse is just beginning a shift on the neuro floor and has the following patients. After receiving report, the nurse determines that the patients should be assessed in which order? A. A patient admitted for stroke who received tPA yesterday and now reports blood in the stool. B. A patient with a spinal cord injury who is complaining of headache, blurred vision, and has a blood pressure of 185/82 mmHg. C. A patient with a spinal cord injury who is on a bowel training program and is scheduled to receive a laxative. D. A patient who had a craniotomy for a brain tumor who is now 3 days post-operative and has had continued emesis. A.B, A, C, D B.B, A, D, C C.B, C, A, D D.A, B, C, D

B. B, A, D, C Rationale: Patients should be seen in the following order:1) Patient with SCI who is experiencing blurred vision, HA, and increased BP. This patient is experiencing autonomic dysreflexia and needs to be treated immediately because failure to resolve AD can result in status epilepticus, stroke, MI, or death 2) Pt with blood in stool following tPA(thrombolytic)administration due to the high risk of bleeding with medication.3) Pt with continued emesis.4) Pt with a scheduled laxative

A client comes to the ER withcomplaints ofsudden weakness, slurred speech, and right side-paralysis. Which question is most important for the nurse to ask at this time? A.Which medications do you take every day? B.How long have you been having symptoms? C.Do you smoke and for how long? D.Have you everhad these symptoms before?

B.How long have you been having symptoms? Rationale: Need to find out if the client is in the timeframe for t-PA (if they are having an ischemic CVA) ASAP. Other questions are pertinent but not urgent in this setting.

A nurse is admitting a client with severe involuntary twisting movements of the limbs and body, and deterioration of the intellect and emotions. Which disease are these manifestations consistent with? A.Dementia of Alzheimer's Type B.Huntington's disease C.Parkinson's disease D.Multiple sclerosis

B.Huntington's disease Rationale: Huntington's disease is a genetically transmitted, autosomal dominant disorder; clinical manifestations are a movement disorder (characterized by abnormal and excessive involuntary movements called chorea) and cognitive (more variable and involves changes in perception, memory, attention, and learning) and psychiatric disorders (depression, anxiety, agitation, etc.). Eventually, all psychomotor processes are impaired

After change-of-shift report, which patient should the nurse assess first? A.Patient with a bilateral headache described as "like a band around my head" B.Patient with myasthenia gravis who is reporting increased muscle weakness C.Patient with Parkinson's disease who has developed cogwheel rigidity of the arms D.Patient with seizures who is scheduled to receive a dose of phenytoin

B.Patient with myasthenia gravis who is reporting increased muscle weakness Rationale: Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

A 17 year old is brought in by ambulance after sustaining an injury during a football game.The patientbriefly lost consciousness following the injury, regained consciousness temporarily, and then became unresponsive. The nurse will implement which priority action? A.Initiate high-dose barbiturate therapy. B.Prepare for a craniotomy. C.Prepare to insert a ventriculostomy. D.Prepare the patient for a cerebral angiogram.

B.Prepare for a craniotomy. Rationale: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Ventriculostomy would be indicated in hydrocephalus or incidents of increased ICP where ICF may need to be drained.

The nurse implements which intervention for thepatientwith a T3spinal cord injury that is having problems with incontinence and urinary retention? A.Catheterize the patient for residual after voiding B.Teach the patient to self-catheterize. C.Use Crede' method to empty the patient'sbladder. D.Assist the patient to the toilet every 2 hours.

B.Teach the patient to self-catheterize. Rationale: The patienthas an upper motor neuron injury which means the bladder is spastic. This causes reflex voiding and also retention. This will always be a problem, so teaching the patient to self-catheterizeis imperative and will help them regain independence. Assisting this client to the toilet will not help with bladder emptying. Crede' is not appropriate because the bladder is not flaccid. Catheterizing after voiding will not help with bladder emptying.

The nurse is working with an unlicensed assistive personnel (UAP). The nurse should make which determination before delegating a task to the UAP? A.The UAP's ability to prioritize. B.That the task is within the UAP's scope of practice. C.The UAP's rapport with the clients. D.Whether the nurse can more efficiently complete the task without assistance.

B.That the task is within the UAP's scope of practice. Rationale: The UAP's ability to prioritize, rapport with clients, and who can do the job more efficiently are not one of the five rights of delegation. The nurse should delegate to the UAP based upon whether the task is within the UAPs scope of practice -one of the rights of delegation.

The nurse is monitoring the cerebral perfusion pressure for a patient with a head injury. The patient's arterial blood pressure is 110/66 mmHg and intracranial pressure is 26mmHg. Using this assessment data to calculate the patient's cerebral perfusion pressure, the nurse determines that A.The cerebral perfusion pressure is adequate for normal cerebral blood flow. B.To prevent cerebral hypoxemia the patient's blood pressure should be increased. C.The cerebral perfusion pressure is too low and will result in cerebral ischemia and neuronal death. D.Decreasing the patient's blood pressure will increase cerebral blood flow.

B.To prevent cerebral hypoxemia the patient's blood pressure should be increased. Rationale: MAP = [SBP + 2(DBP)] / 3 MAP = 81 =110+ 2(66) ICP = 263 CPP = 81 -26= 55 Normal CPP is 60 -100.8.

The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mmHg and oxygen saturation of 90%.In which order will the nurse implement the actions?Put a comma and space between each answer choice (a,b,c,d,etc.)____________________ a.Obtain blood and urine cultures. b.Give vancomycin (Vancocin) 1g IV. c.Infuse vasopressin (Pitressin) 0.01units/min. d.Administer normal saline 1000mL over 30 minutes. e.Titrate oxygen administration to keep O2 saturation>95%.

E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics

The nurse is caring for a patientin hypovolemic shock receiving intravenous fluid replacement at a rate of 125 mL/hr. Upon admission, the patient'svital signs were BP 105/80, HR90, RR 26, temp 98.0*F. The patient'scurrent vital signs are BP 92/48, HR 118, RR28, temp 98*F. Urinary output is 15mL/hr. To prevent the patient from developing MODS, thenurse contacts the physician anticipating an order for A.administration of 2 units Packed Red Cells B.additional fluid replacement C.IV sympathomimetic such as dopamine D.obtaining an arterial blood gas

B.additional fluid replacement In the progressive stage of shock, aggressive interventions are needed to prevent the development of MODS. If the client's vital signs are continuing to deteriorate this shows that the patient needs additional fluids. Sympathomimetics such as dopamine may be administered after the patient has adequate fluid volume. Fluid replacement should be with crystalloids not blood products.

A patient with a history of a 4-cm abdominal aortic aneurysm is admitted to the emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include A.admission to intensive care for observation and diagnostic testing. B.immediate surgery. C.a STAT angiogram. D.a paracentesis when vital signs are stabilized with fluid replacement.

B.immediate surgery. Rationale:The patient's history and clinical manifestations are consistent with rupture into the retroperitoneal space, and the patient will need immediate surgery to have a chance at survival. The other listed treatments will all be too time consuming

When caring for an infant with suspected hydrocephalus, the nurse understands that the priority nursing intervention is A.maintaining strict aseptic technique when providing care B.obtaining daily head circumference C.recording accurate intake and output D.offering small frequent feedings

B.obtaining daily head circumference Rationale: priority is to measure head circumference to determine increasing hydrocephalus and possible increasing ICP. The other options may/will occur, but are not the highest priority.

A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?Put a comma and space between each answer choice(a,b,c,d,etc.)____________________ a.Obtain CT scan without contrast .b.Infuse tissue plasminogen activator(tPA). c.Administer oxygen to keep O2 saturation>95%. d.Use National Institute of Health Stroke Scale to assess patient

C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. ACT scan will be needed to rule out hemorrhagic stroke before tPA can be administered

When caring for a client with myelomeningocele prior to surgical repair, the priority nursing intervention(s)would be to (Select all that apply.) A.keep the skin clean and dry to prevent irritation from diarrhea stools. B.apply a heat lamp to facilitate drying and toughening of the sac. C.place the child prone to avoid compression of the sac. D.watch for signs of increased ICP. E. monitor head circumference and watch for bulging fontanels.

C, D, E Rationale: A complication of myelomeningocele is hydrocephalus, therefore must watch for s/s of increased ICP and monitor head circumference and watch for bulging fontanels. Sac should be kept moist, therefore keeping it dry and applying a heat lamp are incorrect. The child should be placed in prone position to avoid compression of the sac.

To assess for cranial nerve VII, the nurse will perform which of the following? Select all that apply. A.gag reflex B.confrontation C.corneal reflex test D.light touch to the face E.smile, frown, then close eyes F.salt and sugar discrimination

C, E, F Rationale: CN VII is the facial nerve. It is assessed with the corneal reflex test, smile, frown and close eyes; and salt and sugar discrimination. Gag reflex is used to evaluate the glossopharyngeal (CN IX) and vagus (CN X) nerves. Confrontation is used to assess the optic nerve (CNII). Light touch to the face and the corneal reflex test are used to evaluate the trigeminal (CN V) nerve.

The nurse is taking a history at noon from a client just admitted to the rehabilitation unit following a T4 spinal cord injury. Which statement, if made by the client, would require immediate further investigation by the nurse? A."I had several loose stools yesterday." B."I've been having a lot of muscle spasms lately." C."I haven't catheterized myself since last night." D."I only slept a couple of hours last night."

C."I haven't catheterized myself since last night." Rationale:The client is at risk for autonomic dysreflexia. A full bladder is a common trigger for this. While the other complaints warrant further investigation, these complaints are not priority.

The nurse is caring for a patient with a head injury. The patient does not respond in any way to verbal commands from the nurse. Upon depressing the nail bed on the patient's right hand: the patient opens eyes in response to the nursetalking, curses and mumbles in responseto painful stimulus, and attempts to move hisright handaway from painful stimulus. The nurse determines the patient's Glasgow Coma Score to be A.12 B.9 C.11 D.8

C.11 Rationale: GCS is 11. Best eye response -3(opens eyes to verbal stimulus); Best Verbal Response -3(saying inappropriate words-cursing, and is mumbling); Best Motor Response -5(patient is clearlylocalizing pain, as he isattemptingto remove right hand from stimulus).

The nurse administers edrophonium chloride to the patient with suspected Myasthenia Gravis. Upon noting increased muscle weakness, sweating, excessive salivation, and pupillary constriction, the nurse anticipates implementing which priority intervention? A.Preparing the patient for an emergency thymectomy. B.Administering Tensilon. C.Administering atropine. D.Preparing the patient for plasmapheresis.

C.Administering atropine. Rationale: The patient is experiencing a cholinergic crisis as evidenced by the increased muscle weakness, sweating, excessive salivation, and pupillary constriction following Tensilon administration. Atropine is a cholinergic antagonist and the antidote to Tensilon. An anticholinesterase agent will exacerbate this condition. Plasmapheresis and thymectomy are used for myasthenic crisis andfor improvement of symptoms for patients with MG.

Which intervention would the nurse include in the plan of care for a patient with impaired verbal communication related to expressive aphasia? A.Instruct the client to practice facial and tongue exercises. B.Educate the family about the client's hearing loss. C.Ask the client simple questions that can be answered with "yes" or "no". D.Develop a list of words that the client can practice reading and reciting.

C.Ask the client simple questions that can be answered with "yes" or "no".

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? A.Use an external "condom" catheter to protect the skin and prevent embarrassment. B.Limit fluid intake to 1200 mL daily to reduce urine volume. C.Assist the patient onto the bedside commode every 2 hours. D.Perform intermittent catheterization after each voiding to check for residual urine.

C.Assist the patient onto the bedside commode every 2 hours. Rationale:Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and useof a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown

A new nurse observes an experienced nurse documenting an incorrect amount of narcotic remaining in a PCA pump. What would be the best initial action for the new nurse to take? A.Leave a note for the unit manager requesting an in-service class. B.Do nothing since patient safety isn't an issue. C.Bring the error to the nurse's attention. D.Notify the charge nurse of the error.

C.Bring the error to the nurse's attention. Rationale:All nurses share accountability for accurate documentation and safe practice. Direct communication is the best option to avoid possible miscommunication.

While caring for a patient admitted following a head injury, the nurse notes baseline vital signs of:temperature 98.4F, blood pressure 120/66, heart rate 112, and respirations are 26. One hour after admission, the nursenotes the development of Cushing's triad when the client's vital signs are A.blood pressure 110/70, pulse 127and respirations 20. B.blood pressure 130/72, pulse 90, and respirations 26. C.blood pressure 144/58, pulse 56, and respirations 13. D.blood pressure 158/78, pulse 120 and respirations 8.

C.blood pressure 144/58, pulse 56, and respirations 13. Rationale: Cushing's triad is characterized by systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and altered respirations.

Several hours following a surgical repair of an abdominal aortic aneurysm, the patient develops left flank pain and a urinary output of 20 ml/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for a(n) A.increase in IV rate. B.additional antibiotic. C.blood urea nitrogen (BUN) and creatinine. D.complete blood count.

C.blood urea nitrogen (BUN) and creatinine. Rationale:The pain and decreased urine output suggest a renal artery embolism, and monitoring of renal function is needed. The data are not consistent with the complication of infection, hypovolemia, or bleeding

The nurse is caring for a patient involved in a rodeo injury resulting incomplete transection of the spinal cord at T-1. At this time the client's blood pressure is 98/60, heart rate is 48, extremities are warm, and urine output has decreased to 15mL/hour. The nurse believes the patient to be experiencing A.spinal shock. B.autonomic dysfunction syndrome. C.neurogenic shock. D.autonomic dysreflexia.

C.neurogenic shock. Rationale: Neurogenic shock occurs with a SCI at or above T-6. Clinical manifestations include bradycardia, hypotension, warm extremities, and decreased UO due to decreased perfusiondue to a loss of SNS. Spinal shock involves decreased reflexes, loss of sensation, and flaccid paralysis below the level of injury, which typically resolves within days to months. Autonomic dysreflexia is a neurologic emergency

The nurse will include which information while teaching the patient with Parkinson's Disease that is struggling with bradykinesia and rigidity? Select all that apply. A.Teach thepatient to take small steps in a straight line directly in front of the feet. B.Teach the patient to keep the feet in contact with the floor and slide themforward. C.Instruct the patient in activities that can be done while lying or sitting. D.Suggest that the patient rock from side to side to initiate leg movement. E.Instruct the patient to pick up foot with each step and pretend he is stepping over a line to avoid shuffling gait.

D & E Rationale: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

The patient being treated for an ischemic stroke is receiving tissue plasminogen activator (tPA). The nurse understands that the priority assessment with this treatment is A.cerebral perfusion pressure. B.cardiac functioning. C.blood pressure changes. D.neurological status.

D. neurological status. Rationale: It is important to frequently assess neuro status. This will quickly change in clients receiving tPA. Dramatic improvement or decline from intracerebral hemorrhage can be detected through close monitoring of neuro status. The other options need to assessed as well but the most important to monitor is neuro status.

A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which client statement indicates an understanding about management of the disease at home? A."I should drink at least 2 liters of fluid daily." B."I should limit my sodium intake to 2 grams daily." C."I should report constipation or fatigue immediately." D."I should limit my fluid intake to between 800-1200 mL per day."

D."I should limit my fluid intake to between 800-1200 mL per day." Rationale:Excess secretion of ADH causes fluid retention and dilutes serum. Limiting fluid intake is the treatment of choice.

The nurse in an emergency department has admitted five clients in the last two hours with similar complaints of fever and gastrointestinal distress. Which question would be most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat? A."Can you write down everything you ate today?" B."Do you work or live near any major power lines?" C."What other health problems do you have?" D."Where were you immediately before you got sick?"

D."Where were you immediately before you got sick?" Rationale:The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location exhibiting similar signs/symptoms.

Which of the following should the nurse assess to provide the most accurate information about a client suspected of having a C4 injury? A.Ask the client to straighten the flexed arms while applying resistance. B.Ask the client to grasp an object and make a fist. C.Ask the client to lift the legs while applying resistance. D.Ask the client to shrug the shoulders while applying downward pressure.

D.Ask the client to shrug the shoulders while applying downward pressure. Rationale: In order to assess the extent of the injury, must assess whether or not patient has innervation of the shoulders and arms.

When caring for a patient who has Guillain-Barre syndrome, which assessment data obtained by the nurse will require the most immediate action? A.Patient complains of bowel and bladder dysfunction. B.Patient has facial flushing and is diaphoretic. C.Patient complains of severe tingling pain in the feet. D.Patient has continuous drooling of saliva.

D.Patient has continuous drooling of saliva. Rationale: Paresthesia is a frequent occurrence. Bowel and bladder dysfunction is a result of autonomic dysfunction, but is not the most dangerous complication or manifestation associated with GB. The most serious complication of GB is respiratory failure. Continuous drooling is suggestive that the patient has an impairment of their respiratory function and may need immediate intervention including intubation and mechanical ventilation. Facial flushing and diaphoresis are other autonomic dysfunctions associated with GB. However, they are not as serious or life threatening

The patient has an impairment of cranial nerve VIII. Specific to this impairment, the RN would plan to do which of the following to ensure client safety? A.Test the temperature of the shower water. B.Provide a clear path for ambulation without obstacles. C.Check the temperature of the food on the dietary tray. D.Speak loudly to the client.

D.Speak loudly to the client. Cranial nerve VIII is vestibulocochlear, which involves hearing and balance. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerve II is the optic nerve, which governs vision. The RN can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

What guides the RN's decision about the minimal level that the RN should practice by? A.ANA Code of Ethics. B.National League of Nursing. C.Policy and Procedure of the individual facility. D.State Practice Act.

D.State Practice Act. Rationale: Each state has a nurse practice act that dictates legal nurse practice and the minimal level the nurse should practice by.

A 10 year old male child with spina bifida has a neurogenic bladder. His parents have been managing this by performing clean intermittent catheterization. Which recommendation by the nurse would be appropriate at this time? A.Continue to have the parents perform the catheterizations. B.Encourage the family to seek surgical interventions for urinary diversions. C.Begin timed voiding to manage incontinence. D.Teach the child to perform self-catheterization.

D.Teach the child to perform self-catheterization. Rationale:The child is school age and is able to manage his own intermittent catheterizations.

A client with a T1 spinal cord injury is admitted to the intensive care unit (ICU). What is the most accurate information the nurse can give the client concerning his/her injury? A.The client will not able to drive a car. B.The client will able to walk independently with leg braces. C.The client will need assistance transferring into wheelchair. D.The client will be able to use his arms to propel his own wheelchair independently.

D.The client will be able to use his arms to propel his own wheelchair independently. Rationale: Client's with a T1 injury can transfer independently into the wheelchair and propel independently. At T6 and below the client can walk with leg braces. The client may be able to drive a car with hand controls.

A five year old is admitted with a diagnosis of Reye's syndrome. Why does the nurse know that monitoring intake and output is a priority intervention? A.The client may experience acute renal failure. B.The client will experience polydipsia. C.Changes in liver function commonly occur with Reye's syndrome. D.There is continuous adjustment of fluids to prevent dehydration and cerebral edema.

D.There is continuous adjustment of fluids to prevent dehydration and cerebral edema. Rationale:Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema in the child with Reye Syndrome. Careful monitoring of intake and output is apriority. Polydipsia is increased thirst which is not a consideration in Reyes. I & O monitoring is not related to the liver dysfunction and acute renal failure is not a complication of Reyes.

When planning long term care for a child with cerebral palsy, it is important for the nurse to recognize that the A.child probably has some degree of mental retardation. B.effects of cerebral palsy are unstable and unpredictable. C.child should have genetic counseling before planning a family. D.illness is not progressively degenerative.

D.illness is not progressively degenerative. Rationale:The damage is fixed at the time of insult or development. p 1188It cannot be assumed that all children with CP are mentally retarded. CP is a non- progressive chronic condition. CP is not genetic but r/t anoxia in the pre, peri, or postnatal period.

In order to quickly determine if the patient at risk for shock has adequate end organ perfusion, the nurse will assess A.blood pressure, pulse rate, and respirations. B.breath sounds, blood pressure, and body temperature. C.blood pressure, level of consciousness, and pupillary response. D.level of consciousness, urine output and skin color.

D.level of consciousness, urine output and skin color. Rationale:LOC (Cerebral), urine output (Cardiac, Renal, Tissue) and Skin Color (Peripheral)will provide evidence of end organ perfusion/adequate tissue perfusion. Blood pressure does not reflect tissue perfusion.

The nurse is caring for a patient that was involved in a near-drowning. The nurse will observe the patient for at least 24hours to monitor for symptoms of A.hyperatnatremia. B.hypothermia. C.head injury. D.pulmonary edema and respiratory distress.

D.pulmonary edema and respiratory distress.

During the admission assessment of a client with Parkinson's disease, the nurse would expect to see which symptoms? A.diplopia, tremor, bradykinesia B.spasticity, diplopia, bradykinesia C.ataxia, drowsiness, dysarthria D.tremor, rigidity, bradykinesia

D.tremor, rigidity, bradykinesia Rationale: tremor, rigidity, and bradykinesia are the triad of symptoms for Parkinson's disease.

The following actions are part of the routine emergency department(ED )protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a.Remove the patients rings. b.Place ice packs on both hands. c.Apply calamine lotion to any itching areas. d.Give diphenhydramine (Benadryl) 100mgPO.

a.Remove the patients rings. The patients rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry.

The nurse is caring for a child in the ED that is sitting in tripod position, drooling and has a froglike croaking sound with inspiratory stridor. After assessing the patient, the nurse anticipates performing which interventions: Select all that apply. A.Monitoring pulse oximetry. B.Obtaining a throat culture. C.Maintaining a patent airway. D.Providing humidified oxygen. E.Administering corticosteroids and antibiotics.

a, c, d, e Rationale: Epiglottitis is an acute inflammation and swelling of the epiglottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction. Therefore the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction.

A patient arrives in the emergency department (ED) a few hours after taking "20 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Have the patient drink large amounts of water. d. Administer oxygen using a non-rebreather mask.

a. Give N-acetylcysteine (Mucomyst). N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Observe the patient's respiratory effort b. Check the patient's LOC c. Palpate extremities for capillary refill time d. Examine the patient for any external bleeding

a. Observe the patient's respiratory effort Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. Ultrasonography b. peritoneal lavage c. nasogatric tube placement d. magnetic resonance imaging

a. Ultrasonography For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding.

When teaching a patient with myasthenia gravis(MG) about management of the disease, the nurse advises the patient to a. perform physically demanding activities in the morning. b.anticipate the need for weekly plasma pheresis treatments. c.do frequent weight-bearing exercise to prevent muscle atrophy. d.protect the extremities from injury due to poor sensory perception.

a. perform physically demanding activities in the morning Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued .There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital. Which of these patients will the nurse need to assess first? a.A patient with a red tag b.A patient with a blue tag c.A patient with a yellow tag d.A patient with a green tag

a.A patient with a red tag The red tag indicates a patient with a life-threatening injury requiring rapid treatment The other tags indicate patients with less urgent injuries or those who are likely to die.

A patient with a myotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a.Assist with active range of motion. b.Observe for agitation and paranoia. c.Give muscle relaxants as needed to reduce spasms. d.Use simple words and phrases to explain procedures.

a.Assist with active range of motion. ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patients ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

While admitting a patient with a basal skull fracture ,the nurse notes clear drainage from the patients nose. Which of these admission orders should the nurse question? a.Insert nasogastric tube. b.Turn patient every 2 hours. c.Keep the head of bed elevated. d.Apply cold packs for facial bruising

a.Insert nasogastric tube. Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a.impaired physical mobility related to right hemiplegia. b.risk for injury related to denial of deficits and impulsiveness. c.impaired verbal communication related to speech-language deficits. d.ineffective coping related to depression and distress about disability.

b. risk for injury related to denial of deficits and impulsiveness. Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of a. blood. b. vaccine. c. atropine. d. antibiotics.

b. vaccine. Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.

Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia? a.Teach facial and jaw relaxation techniques. b.Assess intake and output and dietary intake. c.Apply ice packs for no more than 20 minutes. d.Spend time at the bedside talking with the patient.

b.Assess intake and output and dietary intake. The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

After noting that a patient with a head injury has clear nasal drainage ,which action should the nurse take? a.Have the patient blow the nose. b.Check the nasal drainage for glucose. c.Assure the patient that rhinorrhea is normal after a head injury. d.Obtain a specimen of the fluid to send for culture and sensitivity.

b.Check the nasal drainage for glucose. Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid(CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage

Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine(Mestinon) . An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a.Auscultate the patients bowel sounds. b.Notify the patients' healthcare provider. c.Administer the prescribed PR Nantiemetic drug. d.Give the scheduled dose of prednisone (Deltasone).

b.Notify the patients' healthcare provider. The patients history and symptoms indicate a possible cholinergic crisis. The healthcare provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a.This type of monitoring system is complex and highly skilled staff are needed. b.The monitoring system helps show whether blood flow to the brain is adequate. c.The ventriculostomy monitoring system helps check for alterations in cerebra lperfusion pressure. d.This monitoring system has multiple benefits including facilitation of cerebro spinal fluid drainage

b.The monitoring system helps show whether blood flow to the brain is adequate. Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members anxiety

Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a.Hemoglobin is within normal limits. b.Urine output is 60mL over the last hour. c.Pulmonary artery wedge pressure (PAWP) is normal. d.Mean arterial pressure (MAP) is 65mmHg

b.Urine output is 60mL over the last hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion

A client with trigeminal neuralgia returns to the clinic for follow-up. Which assessment is most important for the nurse to perform for the client with trigeminal neuralgia? a. skin temperature b. determining areas of pain through palpation c. examination of dentition d. perform cranial nerve IX and X assessment

c. examination of dentition This answer is correct because assessment of teeth and gums are important because dental care is often not performed for fear of pain associated with the oral care. Most pain is experienced in the upper or lower jaw and runs in cycles. Examination of dentition is important because dental hygiene is very important to one's health.

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a.Cool, clammy skin b.Inspiratory crackles c.Apical heart rate 48beats/min d.Temperature 101.2F(38.4C)

c.Apical heart rate 48beats/min Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock

A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period? a.Listen to heart sounds. b.Palpate peripheral pulses. c.Auscultate breath sounds. d.Check pupil reaction to light.

c.Auscultate breath sounds. Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse ,but it is not as pertinent to the patients admission diagnosis

An unresponsive 75-year-old is admitted to the emergency department (ED) during a summer heat wave. The patients core temperature is 106.2F(41.2C), blood pressure (BP)86/52, and pulse110. The nurse initially will plan to a.administer an aspirin rectal suppository. b.start O2 at 6L/min with a nasal cannula. c.apply wet sheets and a fan to the patient. d.infuse lactated Ringers solution at 1000mL/hr.

c.apply wet sheets and a fan to the patient. The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through anon-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000mL/hr.

After receiving 1000mL of normal saline ,the central venous pressure for a patient who has septic shock is 10mmHg, but the blood pressure is still 82/40mmHg. The nurse will anticipate the administration of a.nitroglycerine (Tridil). b.drotrecoginalpha (Xigris). c.norepinephrine (Levophed). d.sodium nitroprusside (Nipride)

c.norepinephrine (Levophed). When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance(SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam (Valium) tablets. Which action will the nurse plan to take first? a. Administer activated charcoal. b. Insert a large-bore orogastric tube. c. Prepare a 60-mL syringe with saline. d. Assist with intubation of the patient.

d. Assist with intubation of the patient. In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F, which assessment indicates that the nurse should discontinue the rewarming? a. The patient stops shivering. b. The BP decreases to 85/40 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

d. The core temperature is 94° F (34.4° C). A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient.

A client was brought into the ER for a stroke, but did not receive tissue plasminogen activator (tPA). Which answer below is the best rationale for this? a. the client is on aspirin therapy b. the client was brought to the hospital four hours after symptom onset c. the client experienced an ischemic stroke d. the client experienced a hemorrhagic stroke

d. the client experienced a hemorrhagic stroke This answer is correct because a hemorrhagic stroke is caused by a weak blood vessel that ruptures and bleeds into the brain. TPA is a thrombolytic and works by dissolving clots to restore perfusion to the brain after a stroke. Since tPA resolves clots, it is not given because it will make the hemorrhage worse. there is no association between aspirin therapy and tPA treatment. Although the antiplatelet properties of aspirin can make bleeding worse in hemorrhagic strokes, it is not the best rationale as to why the client did not receive tPA. the client was within the window of treatment for administration of tPA. TPA should be administered no longer than 3 to 4.5 hours of symptoms onset for a more positive outcome. the most effective treatment for ischemic stroke is tPA. It is given intravenously to dissolve the blood clot causing the stroke.

After receiving change-of-shift report, which patient will the nurse assess first? a.A patient with cystic fibrosis who has thick, green-colored sputum b.A patient with pneumonia who has coarse crackles in both lung bases c.A patient with emphysema who has an oxygen saturation of 91% to 92% d.A patient with septicemia who has intercostal and suprasternal retractions

d.A patient with septicemia who has intercostal and suprasternal retractions This patients history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status

A patient who has numbness and weakness of both feet is hospitalized with Guillain- Barr syndrome. The nurse will anticipate the need to teach the patient about a.intubation and mechanical ventilation. b.administration of IV corticosteroid drugs. c.insertion of a nasogastric(NG) feeding tube. d.IV infusion of immunoglobulin (Sandoglobulin)

d.IV infusion of immunoglobulin (Sandoglobulin) Because the Guillain-Barr syndrome is in the earliest stages(as evidenced by the symptoms),use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome

When assessing a patient with a possible stroke, the nurse finds that the patients aphasia started 3.5 hours previously and the blood pressure is 170/92mmHg. Which of these orders by the health care provider should the nurse question? a.Infuse normal saline at 75mL/hr b.Keep head of bed elevated at least 30 degrees. c.Administer tissue plasminogen activator (tPA) per protocol. d.Titrate labetalol (Normodyne) drip to keep BP less than 140/90mmHg.

d.Titrate labetalol (Normodyne) drip to keep BP less than 140/90mmHg. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP)is>130mmHg or systolic pressure is >220mmHg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

A42-year-old patient who was adopted at birth is diagnosed with early Huntington's disease(HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a.use of levodopa-carbidopa(Sinemet) to help reduce HD symptoms. b.need to take prophylactic antibiotics to decrease the risk for pneumonia. c.lifestyle changes such as increased exercise that delay disease progression. d.availability of genetic testing to determine the HD risk for the patients children.

d.availability of genetic testing to determine the HD risk for the patients children. Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD

When the nurse is developing are habilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a.transfer independently to a wheelchair. b.drive a car with powered hand controls. c.turn and reposition independently when in bed. d.push a manual wheelchair on flat,smooth surfaces.

d.push a manual wheelchair on flat, smooth surfaces. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed