NSG 460 Exam 6 Practice Questions
A pt is admitted with a subacute subdural hematoma. The nurse realizes this pt will most likely be treated with: A. emergency craniotomy B. elective draining of the hematoma C. burr holes to remove hematoma D. removal of the affected cranial lobe
B. elective draining of the hematoma
When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first? A. the area proximal to the fracture B. the actual fracture site C. the area distal to the fracture D. the opposite extremity for baseline comparison
C. the area distal to the fracture
A client is admitted to the hospital 24 hrs ago after sustaining blunt trauma. For which early clinical manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor for? A. crackles throughout lung fields B. increase in respiratory rate from 18 to 24 breaths/min C. "white-out" appearance of lungs on chest radiograph D. cyanosis and pallor
B. increase in respiratory rate from 18 to 24 breaths/min
Following cerebral angiography, a pt is found to have carotid artery dissection. What critical complication associated with this injury should the nurse be most concerned about because it could lead to a stroke? A. concussion B. hemorrhage C. diffuse axonal injury D. coma
B. hemorrhage
A pt with traumatic brain injury is experiencing cerebral edema, which has led to severely elevated ICP. He has increased pulse pressure, decreased HR, and an irregular respiratory pattern. He has lost consciousness and demonstrates bilateral pupillary dilation. The nurse recognizes that these symptoms point to which condition? A. central herniation syndrome B. uncle herniation syndrome C. cerebrovascular injury D. diffuse axonal injury
A. central herniation syndrome
A pt with traumatic brain injury is found to have bilateral lesions deep in the cerebral hemispheres. What respiratory pattern should the nurse most expect to find in this pt? A. alternating hyperapneic and apneic phases (Cheyne-Stokes breathing) B. sustained, regular, rapid and deep hyperventilation (neurogenic hyperventilation) C. long pause at full inspiration or full expiration (apneustic breathing) D. gasping breaths with irregular pauses (cluster breathing)
A. alternating hyperapneic and apneic phases (Cheyne-Stokes breathing)
This is an ABG on a trauma pt: pH 7.30, PaO2 250, PaCO2 30, HCO3 16, Base Deficit 12.7. This most likely indicates: A. closed head injury B. inadequate tissue perfusion C. Pulmonary injury D. spinal cord injury
B. inadequate tissue perfusion
A 30 yo female arrives in the ED after a MVC. Unresponsive at the scene she arrives intubated. Her VS are HR 100, BP 140/90, RR 16 (assisted). The change is VS are more likely a result of: A. early hypovolemic shock B. increased ICP C. neurogenic shock D. pain
B. increased ICP
A client with trauma to the chest develops a tension pneumothorax. After a needle thorocostomy is performed the nurse would expect: A. an increase in BP B. a decrease in BP C. and increase in JVD D. a decrease in LOC
A. an increase in BP Rationale: Clients presenting with tension pneumothorax would exhibit hypotension, jugular venous distension, and decreasing level of consciousness. An increase in blood pressure should result after a thoracostomy is performed.
54 hours after sustaining deep partial thickness burns to both lower extremities and his abdomen, the pt's urine output has increased from 1000cc to 2300cc in 24 hrs. His labs are: Na 137, K 4.4, HCT 38%. These finding suggest: A. beginning of the interstitial to plasma fluid shift B. circulatory overload C. early coagulopathy D. early renal failure secondary to volume depletion
A. beginning of the interstitial to plasma fluid shift
A client with a head injury is being monitored for ICP. His BP is 90/60 and the ICP is 18; therefore his CPP is: A. 52 mm Hg B. 88 mm Hg C. 48 mm Hg D. 68 mm Hg
A. 52 mm Hg Rationale: MAP=Systolic+Diastolic(x2)/3 90+60(2)=210 90+120=210 210/3=70 MAP=70 CCP=MAP-ICP 70-18=52 CCP=52
After failing to effectively clear a pt's airway by having him cough, the nurse is now suctioning his airway. What complication related to suctioning should the nurse be aware of? A. bradycardia B. tachycardia C. hyperglycemia D. hypertension
A. bradycardia
A client who was in a motor vehicle accident a few days ago is now complaining of progressive weakness in his arms and upper body while the functioning of his lower limbs is unchanged. Which of the following might this client be experiencing? A. central cord syndrome B. whiplash syndrome C. anterior cord syndrome D. Brown-Sequard syndrome
A. central cord syndrome Rationale: In central cord syndrome, motor and sensory function of the upper extremities is lost while the functioning of the lower extremities stays intact.
An inexperienced nurse who is new to the ICU is examining the eyes of a comatose patient with traumatic brain injury who is on a ventilator. In doing so, she turns the patient's head sharply to one side. After she is finished, she leaves the patient's head turned to the side. A more experienced nurse sees this and cautions the new nurse not to turn the patient's head so sharply or leave it in that position. What is the best rationale for the more experienced nurse's admonition? A. Compression of the jugular vein leading to increased intracranial pressure B. Lack of a patent airway C. Lack of dignity for the patient D. Cramping of neck muscles
A. Compression of the jugular vein leading to increased intracranial pressure
The patient has an acute subdural hematoma from an acute head injury. What is the most typical symptom that the nurse would expect during the first 2 days after the injury? A. Decreasing level of consciousness B. Labile blood pressure C. Cardiac dysrhythmias D. Impingement of cranial nerve 8
A. Decreasing level of consciousness
A pt is admitted with a ruptured spleen following an ATV accident, he is being prepared for surgery and the nurse suspects he is in the compensatory stage of shock. This assessment is based upon what findings? A. HR 120, BP 110/86 B. anxious, bibasilar crackles C. HR 140, urine output < 30cc/hr D. difficult to arouse, BP 80/60
A. HR 120, BP 110/86
Jeff has a C4/C5 fracture. Which is correct? A. He will need life-long mechanical ventilation B. He is at risk for respiratory fatigue C. he will have full use of his hands D. he can grasp objects weakly
A. He will need life-long mechanical ventilation
A patient has experienced a traumatic brain injury. During initial assessment, the nurse determines that the mechanism of injury was accelerationdeceleration. What is the best rationale for this nursing assessment? A. Helps to predict nature of internal injuries B. Satisfied the nurse's curiosity C. Required on admission form D. May be part of legal evidence
A. Helps to predict nature of internal injuries
A pt arrives in the ER. He is tachycardia and hypotensive. He says: "I have a knife in my chest and I have Beck's triad: muffled heart sounds, JVD and hypotension. I think I have cardiac tamponade. Do you think that's true?" A. True B. False
A. True
You are the triage nurse in a first aid station at a large music festival. Which of the following patients does the physician see first? A. a 55 yo obese male complaining of nausea and epigastric pain B. a 25 yo male with sunburn on his face, back and neck C. am angry vomiting teenager who smells of alcohol D. a screaming toddler with a 4 cm laceration on his forehead
A. a 55 yo obese male complaining of nausea and epigastric pain
Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? A. acute respiratory distress syndrome B. migraine like HAs C. numbness in the right leg D. muscle spasms in the right thigh
A. acute respiratory distress syndrome
A client with head trauma develops a urine output of 300mL/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? A. evaluate urine specific gravity B. anticipate treatment for renal failure C. provide emollients to the skin to prevent breakdown D. slow down the IV fluids and notify the physician
A. evaluate urine specific gravity Rationale: Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.
Based on the nurse's understanding of the physiology of bone and cartilage, the injury that the nurse would expect to heal most rapidly is a: A. fracture of the midhumerus B. torn knee cruciate ligament C. fractured nose D. severely sprain ankle
A. fracture of the midhumerus Rationale: Bone is dynamic tissue that is continually growing. Nasal fracture, sprains, and ligament tears injure cartilage, tendons, and ligaments, which are slower to heal.
A pt who is in a motor vehicle accident struck her forehead on the windshield of her car after crashing into the back of another car. Given this mechanism of injury, which regions of the brain are most likely to be injured? Select all that apply. A. frontal lobe B. parietal lobe C. occipital lobe D. temporal lobe E. diencephalon F. medulla oblongata
A. frontal lobe C. occipital lobe
A 44 yo male is admitted to a burn unit with 2nd and 3rd degree burns on 60% of his body. After 12 hrs, his urine output is 24cc/hr and his ABG is: pH 7.31, PaO2 96 (2L NC), PaCO2 36, HCO 18. The nurse concludes that: A. he is in renal failure and metabolic acidosis B. he is hypoxic from renal failure C. he is in respiratory acidosis from CO2 retention secondary to renal failure D. he is in early CHF from overhydration
A. he is in renal failure and metabolic acidosis
The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracranial hypertension? A. hypoventilation B. elevating the HOB C. hypernatremia D. quiet darkened environment
A. hypoventilation Rationale: Hypoventilation leads to vasodilation and increased intracranial pressure.
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? A. laceration of the middle meningeal artery B. rupture of the carotid artery C. thromboembolism from a carotid artery D. venous bleeding from the arachnoid space
A. laceration of the middle meningeal artery Rationale: Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma
Your client is transported to the ED after sustaining head, back and chest injuries when he fell 25 ft from a tree. The primary survey has been completed. His BP drops to 80/40, HR is 56, RR is 20. BBS are equal and clear. SaO2 is 99%. This data is most consistent with: A. neurogenic shock B. tension pneumothorax C. hypovolemic shock D. closed head injury
A. neurogenic shock
A severely burned client is ordered albumin on the second day of hospitalization. The nurse understands that the rationale for giving albumin is: A. provides protein to increase serum osmotic pressure B. provides fluid to prevent dehydration C. replace clotting factors and prevent bleeding D. replace hemolyzed RBCs and reduce anemia
A. provides protein to increase serum osmotic pressure
Autonomic dysreflexia is an emergency because: A. severe vasoconstriction occurs B. hypoxia results from regurgitation C. spasticity produces joint deformity D. airway spasm occurs
A. severe vasoconstriction occurs
A 72 yo female pedestrian hit by a car is admitted to the ER with bilateral fetal fractures. The priority nursing concern is: A. shock B. infection C. fat embolism D. pain
A. shock
A pt with a major burn receives TPN. The primary reason for this is: A. to insure adequate calories and protein/cholesterol B. to prevent GI obstruction C. to correct fluid and electrolyte imbalance D. to provide supplemental vitamins and minerals
A. to insure adequate calories and protein/cholesterol
A client with subdural hematoma was given mannitol to decrease ICP. Which of the following results would best show the mannitol was effective? A. urine output increases B. pupils are 8mm and nonreactive C. systolic BP remains at 150mmHg D. BUN and Cr levels return to normal
A. urine output increases Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.
You are working in the triage area of an ED, and 4 pts approach the triage desk at the same time. List the order in which you will assess these pts: 1. an ambulatory, dazed 25 yo male with a bandaged head wound 2. an irritable infant with a fever, petechiae, and nuchal rigidity 3. a 25 yo jogger with a twisted ankle, having pedal pulse and no deformity 4. a 50 yo female with moderate abdominal pain and occasional vomiting A. 1 2 4 3 B. 2 1 4 3 C. 3 4 2 1 D. 3 2 1 4
B. 2 1 4 3 Rationale: An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct a nursing assistant to get the crash cart. A. 1 2 3 5 4 B. 2 4 1 3 5 C. 3 1 2 5 4 D. 4 3 2 5 1 E. 5 3 4 2 1
B. 2 4 1 3 5 Rationale: Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.
A teenaged boy jumped from a two-story building and landed on his feet, injuring his spine, and is now in the ICU. The nurse recognizes his injury as which of the following? A. Rotational injury B. Axial loading C. Hyperflexion D. Hyperextension
B. Axial loading
The client with an old C6 spinal cord injury complains of suddenly being too warm, with nasal congestion and a very red face. What is your next assessment? A. temperature B. BP C. I&O for previous 8 hrs D. bowel for impaction
B. BP Rationale: This is autonomic dysreflexia and is usually associated with hypertension. Sit them up quickly.
A patient with a suspected skull fracture is observed to have raccoon eyes, or bilateral periorbital bruising. What other symptom does the nurse expect? A. Positive Battle's sign B. Cerebrospinal fluid rhinorrhea C. Cerebrospinal fluid otorrhea D. Maxillarycranial separation
B. Cerebrospinal fluid rhinorrhea
A patient involved in a snowmobile accident struck a tree and sustained a fractured vertebra at C4. She demonstrates signs of ischemic areas near the injury, along with hypoperfusion, microscopic hemorrhage, and edema. The nurse observes signs of concussion, including loss of consciousness. Which of the following are considered secondary injuries? Select all that apply. A. Fractured vertebra B. Cord ischemia C. Hypoperfusion D. Microscopic hemorrhage E. Edema F. Concussion
B. Cord ischemia C. Hypoperfusion D. Microscopic hemorrhage E. Edema
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe HA, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture would be contraindicated in this client in which of the following circumstances? A. vomiting continues B. ICP is increased C. the client needs mechanical ventilation D. blood is anticipated in the CSF
B. ICP is increased Rationale: Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.
A pt with traumatic brain injury is being assessed. This pt demonstrates gross defects in visual acuity on reading a Snellen eye chart. Which cranial nerve is most likely damaged? A. cranial nerve I B. cranial nerve II C. cranial nerve III D. cranial nerve IV
B. cranial nerve II
A pt involved in a motor vehicle accident has a high risk of spinal cord injury. At the scene, what is the priority pt assessment? A. LOC B. RR C. independent mobility D. peripheral sensation
B. RR
A pt with a spinal cord injury and who smokes is at risk for developing a DVT. The nurse provides the pt with antiembolism stockings and encourages her to stop smoking, as it contributes to vasoconstriction in the periphery and thus to DVT. What other measure would be appropriate to help prevent DVT in this pt? A. administration of atropine sulfate B. administration of heparin C. administration of reserpine D. administration of methyldopa
B. administration of heparin
A pt with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating the HOB, which is the most appropriate nursing action? A. increase IV fluids B. assess for a distended bladder C. apply oxygen at 4L/min D. notify the physician
B. assess for a distended bladder
When the pt is in neurogenic shock, the nurse will assess for: A. mental confusion and tachycardia B. bradycardia and hypotension C. unilateral pupil dilation and hypotension D. hypertension and tachypnea
B. bradycardia and hypotension
A pt was involved in a fight in which he was struck in the back of the head with a blunt object. Scalp laceration is immediately evident. The nurse suspects cerebral edema and ischemia. On CT scan, it appears that he has contusions and a fractured skull. On neurological assessment, the nurse finds evidence of concussion, as the pt demonstrates short-term memory impairment. Of these findings, which are secondary brain injuries? Select all that apply. A. scalp laceration B. cerebral edema C. ischemia D. contusions E. fractured skull F. concussion
B. cerebral edema C. ischemia
A pt with a spinal cord injury complains about a severe throbbing HA that suddenly started a short time age. Assessment of the pt reveals increased BP (168/94) and decreased HR (48), diaphoresis, and flushing of the face and neck. What action should you take first? A. administer the ordered acetaminophen B. check the foley tubing for kinks and obstruction C. adjust the temp in the pt's room D. notify the physician about the change in status
B. check the foley tubing for kinks and obstruction
The nurse is caring for a client with increased ICP. The nurse would note which of the following trends in VS if the ICP is rising? A. increasing temp, increasing pulse, increasing RR, decreasing BP B. increasing temp, decreasing pulse, decreasing RR, increasing BP C. decreasing temp, decreasing pulse, increasing RR, decreasing BP D. decreasing temp, increasing pulse, decreasing RR, increasing BP
B. increasing temp, decreasing pulse, decreasing RR, increasing BP Rationale:A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.
An awake, alert pt in the ED following a MVC is complaining of chest pain and a "wrenched neck." The initial nursing action is: A. open airway B. maintain cervical stability C. elevate head on two pillows and apply oxygen D. perform a secondary assessment
B. maintain cervical stability
Mr. T is admitted to the SICU following an MVC. The initial drainage from a right chest tube inserted in the ED is 400cc. The following hour the chest tube drains 300cc of blood. Which the most appropriate action by the nurse? A. elevate the HOB B. notify the physician C. continue to monitor VS D. "milk" the chest tube
B. notify the physician >200cc/hr should be reported
The most common isolation technique used in burn patients is: A. enteric B. reverse C. wound D. respiratory
B. reverse
Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. absence of pain sensation in chest B. spasticity C. spontaneous respirations D. urinary continence
B. spasticity Rationale: Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.
Which of the following tasks should the nurse have a nursing assistant do first? A. collect a UA B. take an ABG to the lab C. take a pt to radiology for a CXR D. assist a pt to the chair at bedside
B. take an ABG to the lab
A 32 yo burn victim is receiving IV fluids at a rate of 450cc/hr. Hourly CVP readings during the first 4 hrs of therapy follows: 3.5, 4.5, 6.0, 7.5. Which of the following is the best interpretation of this data? A. this indicates fluid overload B. this is an expected response to fluid therapy C. this may indicate inaccurate measurements D. fluid therapy should continue until the CVP is WDL
B. this is an expected response to fluid therapy
If a pt has a burn to the entire left side of his back and the posterior side of his left arm, what is the estimated body surface area burned? A. 36% B. 27% C. 13.5% D. 9%
C. 13.5% (9% left side of back + 4.5% arm)\
The nurse is admitting a client with multiple stab wounds sustained during a gang fight to the emergency room. The nurse knows that it would be most appropriate to obtain initial IV access by establishing a: A. femoral central line B. femoral trauma cordis C. 16G catheter in each ante-cubital fossa D. subclavian triple lumen catheter
C. 16G catheter in each ante-cubital fossa
During an assessment of the pt's motor status with GCS, the pt assumes a posture of abnormal flexion. The nurse would document this finding as: A. 5 B. 4 C. 3 D. 2
C. 3
The nurse is caring for a client who required tube insertion for a pneumothorax. The nurse is aware that the best test to assess for pneumothorax resolution is: A. ABG B. pulse ox C. CXR D. breath sounds
C. CXR
A nurse is caring for a patient with a traumatic brain injury who is paralyzed. The nurse must decide how best to meet the nutritional needs of this patient. What intervention is best to support the nutritional needs of the patient? A. Replace 140% of the patient's resting energy expenditure via parenteral nutrition. B. Meet metabolic demands of the patient within 8 to 10 days of the injury. C. Collaborate with a nutrition support team to meet the patient's nutritional needs. D. Maintain the patient's blood sugar level at 300 mg/dL.
C. Collaborate with a nutrition support team to meet the patient's nutritional needs.
The patient has a depressed skull fracture resulting in a tear of the dura mater. What nursing intervention is most directed at preventing a significant complication of this particular injury? A. Elevating the head of the bed to 15 degrees B. Giving supplemental oxygen by mask C. Ensuring compliance with hand hygiene protocols D. Obtaining consent for surgical repair of fracture
C. Ensuring compliance with hand hygiene protocols
A patient with a mild spinal cord injury becomes light-headed every time she attempts to rise from her bed. At rest, her heart rate and blood pressure are normal. All of her motor, sensory, reflex, and autonomic functions are intact. The nurse recognizes which condition in this patient? A. Spinal shock B. Neurogenic shock C. Orthostatic hypotension D. Central cord syndrome
C. Orthostatic hypotension
About 6 weeks after a concussion injury, the patient is complaining of headaches, decreased attention span, and short-term memory impairment. The patient expresses extreme frustration and anxiety. What is the best nursing intervention? A. Obtain an order for a repeat CT scan B. Admit the patient for a complete neurologic evaluation C. Provide emotional support and explanations D. Refer to psychiatry for evaluation and treatment
C. Provide emotional support and explanations
A client presents in the ED after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis? A. the client reports pain in the affected leg B. a large hematoma is visible in the affected extremity C. the affected extremity is shortened, adducted and extremely rotated D. the affected extremity is edematous
C. the affected extremity is shortened, adducted and extremely rotated
When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best describes a lucid interval? A. an interval when the client's speech is garbled B. an interval when the client is alert but can't recall recent events C. an interval when the client is oriented but then becomes somnolent D. and interval when the client has a "warning" symptom, such as an odor or visual disturbance
C. an interval when the client is oriented but then becomes somnolent Rationale: A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.
A pt was struck in the jaw and had hyperextension of the cervical spine. If the pt has central cord syndrome, what would the nurse most expect? A. full loss of motor function below the lesion B. ipsilateral increased cutaneous pain at the lesion C. arm paralysis with intact motor function in the legs D. full motor paralysis and loss of touch sensation below the lesion
C. arm paralysis with intact motor function in the legs
During the initial assessment of pt with a probable spinal cord injury, the nurse performs a digital rectal exam. What is the best rationale for this exam? A. part of routine admission physical B. checks for fecal impaction C. assesses for sensation or movement D. preliminary for rectal meds
C. assesses for sensation or movement
In conducting a primary survey on a trauma pt, which of the following is considered one of the priority elements of the primary survey? A. complete set of VS B. palpation and auscultation of the abdomen C. brief neurologic assessment D. initiation of pulse ox
C. brief neurologic assessment Rationale: A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.
Which of the following tests in a head injury pt differentiates CSF from mucus? A. pH B. specific gravity C. glucose D. micro-organisms
C. glucose
A pt with a cervical spine fracture has been fitted with a halo vest and is to ambulate for the first time today. What is the priority caring action? A. put rubber corks on the ends of the pins B. pad the edges of the vest to prevent chafing C. have the pt sit on the side of the bed for several minutes D. teach about loss of peripheral vision
C. have the pt sit on the side of the bed for several minutes
When admitting the trauma pt with a diagnosis of pelvic fracture to the ICU, the nurse's initial concerns will focus on: A. peripheral perfusion B. respiratory management C. hemorrhage control D. mental status change
C. hemorrhage control
A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in the client's plan of care? A. provide good perineal care B. pass NG tube to decompress stomach C. keep client warm with extra blankets D. stimulate the anal-rectal reflex
C. keep client warm with extra blankets Rationale: Poikilothermia is a loss of temperature control and is dangerous because the client's body temperature will depend upon the temperature in the environment. The client needs to be kept warm and monitored carefully to avoid thermal injuries from passive warming devices.
An adult arrives in the ED after being assaulted with a baseball bat. He is intubated and becoming progressively more difficult to ventilate. Suddenly he becomes unresponsive and pulseless. What is the priority intervention? A. defibrillation B. transporting pt for angioplasty C. relieving the tension pneumothorax D. correcting the internal bleed
C. relieving the tension pneumothorax
Which of the following s/sx of increased ICP after head trauma would appear first? A. bradycardia B. large amounts of very dilute urine C. restlessness and confusion D. widened pulse pressure
C. restlessness and confusion Rationale :The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.
Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? A. full thickness burns rather than partial thickness B. supinates extremity but unable to fully pronate the extremity C. slow capillary refill in the digits with absent pulse points D. inability to distinguish sharp vs dull sensation in the extremity
C. slow capillary refill in the digits with absent pulse points
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. to reduce intraocular pressure B. to prevent acute tubular necrosis C. to promote osmotic diuresis to decrease ICP D. to draw water into the vascular system to increase BP
C. to promote osmotic diuresis to decrease ICP Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.
An immobilized multi-system trauma pt begins to vomit. The nurse's first action is: A. assess breath sounds B. obtain VS C. turn the pt maintaining spine precautions D. suction the pt
C. turn the pt maintaining spine precautions
A pt is in critical care recovering from a spinal cord injury. As part of shift report, the nurse is told the pt's injury is between C1 and C4 and involves the entire cord. The pt is on a mechanical ventilator. What is the best nursing action to provide for pt safety? A. be sure all side rails are up at all times B. keep bed in low position when unattended C. verify that a functioning bag-mask resuscitator is at the bedside D. place the call light in the pt's hand
C. verify that a functioning bag-mask resuscitator is at the bedside
The physician has ordered a solumedrol infusion for a pt with a spinal cord injury. Solumedrol has been shown to be effective in: A. decreasing cerebral edema B. preventing stress ulcers C. decreasing spinal injury spasticity D. improving motor and sensory functioning
D. improving motor and sensory functioning Solumedrol is given within the first 8 hours of injury
Which of the following is descriptive of a concussion? A. venous blood collects in the subdural space B. petechial hemorrhages cause intermittent amnesia C. a lesion develops opposite the site of trauma D. it is a transient neuronal dysfunction
D. it is a transient neuronal dysfunction
What statement indicates a correct understanding of "log rolling"? A. one nurse can perform the task B. pillows are used for support C. the legs are moved before the head D. keeping the spine straight is the primary concern
D. keeping the spine straight is the primary concern
A pt with a spinal cord injury has been stabilized in the ICU and now must undergo diagnostic testing. Which test would be most appropriate for detecting a fracture of the vertebra? A. MRI B. BUN C. GCS D. CT
D. CT
A patient with a traumatic brain injury is at high risk for a secondary brain injury. What is the best nursing explanation of a secondary brain injury? A. Result of a repeated assault incident B. From a penetrating gunshot wound C. Trauma inflicted by another person D. Cerebral edema and ischemia
D. Cerebral edema and ischemia
A patient with a skull fracture has a positive halo sign. What does this sign indicate? A. Fracture of the anterior fossa B. Presence of a basilar skull fracture C. Impingement of cranial nerves D. Cerebrospinal fluid leak
D. Cerebrospinal fluid leak
A pt is recovering from a lumbar spine injury and requires an immobilization device for this region. Which device would be most appropriate for this pt? A. halo vest B. aspen collar C. minerva brace D. Jewett brace
D. Jewett brace
A nurse is monitoring a pt with spinal cord injury for respiratory complications. Which of the following findings would indicate that the pt should be intubated? A. RR 20 B. vital capacity 30 C. PaO2 90 D. PaCO2 60
D. PaCO2 60
A patient presents to the ICU with a spinal cord injury at C3 and the following: loss of position sense, light touch, and vibratory sense below the level of the injury. However, the patient has retained all motor function and pain and temperature sensation. The nurse suspects that the injury has occurred on what portion of the spinal cord? A. Central B. Lateral C. Anterior D. Posterior
D. Posterior
The nurse is assessing a patient with a spinal cord injury in the ICU. The patient is completely paralyzed from the waist down but has sensation in his shoulders, chest, arms, and hands. He has no control of his bowel or bladder. Which of the following are possible sites for this patient's injury, given his loss of function? Select all that apply. A. C4 B. C7 C. T3 D. T7 E. T12 F. L4
D. T7 E. T12
The nurse is presented with a group of pts in the ED. The nurse knows that which pt needs immediate attention? A. a 12 yo with a 10cm laceration on his face B. a 56 yo man with sternal chest pain C. a tachycardia 1 yo who has had diarrhea for 2 days D. a 14 yo with a bee sting who is wheezing
D. a 14 yo with a bee sting who is wheezing
The following bus accident victims are brought to the ED. Which should be assessed first? A. a 30 yo with a HR of 128 B. a 65 yo with a GCS of 14 C. a 54 yo with an irregular heartbeat D. a 24 yo with high pitched inspiration
D. a 24 yo with high pitched inspiration stridor - intubation/O2 needed
It is change of shift. Of the following pts, who should the nurse see first? A. a pt who needs to use the toilet B. a pt whose colostomy bag is reportedly leaking C. a pt scheduled for a bronchoscopy D. a pt who has just been given morphine
D. a pt who has just been given morphine (resp depression)
A comatose pt with a traumatic brain injury is being tested for cranial nerve damage. The nurse passes a wisp of cotton over the lower conjunctiva of each eye. The pt's lower eyelid in each eye twitches when the cotton makes contact with the cornea. The nurse recognizes that this result indicates which of the following? A. the trigeminal nerve is functioning properly but the facial nerve is not B. the facial nerve is functioning properly but the trigeminal nerve is not C. neither the trigeminal nerve nor the facial nerve is functioning properly D. both the trigeminal and the facial nerves are functioning properly
D. both the trigeminal and the facial nerves are functioning properly
Your trauma pt has a spinal cord transection at the T-1 level. The primary nursing concern is: A. renal status B. skin integrity C. GI function D. cardiovascular status
D. cardiovascular status (Autonomic dysreflexia)
A pt is suspected of having injury to his carotid artery following trauma to his neck after engaging in a fight during a hockey game. Which diagnostic test would be most effective in investigating this injury? A. CT B. MRI C. electroencephalogram (EEG) D. cerebral angiography
D. cerebral angiography
A pediatric client is admitted to the neurologist ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be: A. acceleration B. penetrating C. rotational D. deceleration
D. deceleration Rationale: Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.
A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make? A. observe the color of the fingers B. palpate the radial pulse under the cast C. check the cast for odor and drainage D. evaluate the response to analgesics
D. evaluate the response to analgesics
Its with spinal cord injury may experience both spinal shock and neurogenic shock, and differentiating between the two is essential. What symptoms are unique to neurogenic shock? A. loss of motor and sensory function B. flaccid paralysis below the lesion C. presence of poikilothermia D. hypotension and bradycardia
D. hypotension and bradycardia
A pt with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the pt develops chest pain, tachypnea and tachycardia. The nurse determines that the pt's symptoms are most likely related to fat embolism when assessment of the pt reveals: A. a BP of 100/65 B. anxiety, restlessness, confusion C. warm, reddened areas in the calf D. pinpoint red areas on the upper chest
D. pinpoint red areas on the upper chest Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.
A pt is admitted to the ED after a near-drowning accident. The pt dove head-first into shallow water and has a high BAC. Cardiopulmonary resuscitation was used at the scene. The pt is awake and alert. Considering the mechanism of injury, what is the highest nursing priority? A. check VS often B. obtain an order for radiography studies C. monitor pulse ox closely D. provide cervical spine stability
D. provide cervical spine stability
A client who sustained a spinal cord injury at the T2 level should be assessed for signs of autonomic dysrefelxia because: A. the injury results in loss of the reflex arc B. there has been a partial transaction of the cord C. there is a flaccid paralysis of the lower extremities D. the injury is above the 6th thoracic vertebrae
D. the injury is above he 6th thoracic vertebrae
