Test 2 MS3

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A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?

90 mm Hg

The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse?

"My back is killing me!"

The patient's wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the patient will be healthy again. The nurse explains:

"The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk."

The patient's wife is feeling overwhelmed and tells the nurse that she doesn't know if she can manage to cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The nurse tells her:

"The low-cholesterol diet is one from which everyone can benefit."

The cardiologist has told the patient and family that the diagnosis is hypertrophic cardiomyopathy. Later they ask the nurse what the patient did wrong to cause this condition. The nurse explains:

"This is an inherited condition. You should give serious consideration to having family members screened for it."

The patient's wife is confused about the scheduling of a stent insertion. She says that she thought the angioplasty was surgery to fix her husband's heart problem. The nurse explains to her:

'The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again."

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as

11

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first?

A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F

The physician orders a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be

Adenosine

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?

Administer IV 5% hypertonic saline.

The nurse is to administer 100 mg phenytoin (Dilantin) intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse?

Administer over 5 minutes.

Which nursing interventions would be appropriate after angioplasty? (Select all that apply.)

Assess pedal pulses on the involved limb every 15 minutes for 2 hours Monitor the vascular hemostatic device for signs of bleeding Instruct the patient bend his/her knee every 15 minutes while the sheath is in place

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action?

CVP of 2 mm Hg

The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse?

Contact the physician

The patient has been in chronic heart failure for the past 10 years. He has been treated with beta-blockers and angiotensin-converting enzyme inhibitors as well as diuretics. His symptoms have recently worsened, and he presents to the ED with severe shortness of breath and crackles throughout his lung fields. His respirations are labored and arterial blood gases show that he is at risk for respiratory failure. Which of the following therapies may be used for acute, short-term management of the patient? (Select all that apply).

Dobutamine Intraaortic balloon pump Nesiritide (Natrecor)

The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find?

Dyspnea and crackles

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

Encourage family members to remain at the bedside.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

Ensure that the patient's neck is in neutral position.

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?

ICP is high; CPP is normal.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

Immunize adolescents and college freshman.

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action?

Implement seizure precautions.

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

Intracranial pressure

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)

Jugular venous distention Peripheral edema

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Keep the head of the bed elevated to 30 degrees.

A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life?

Left ventricular assist device (LVAD)

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse?

Provide rest periods between nursing interventions.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

Restrict oral fluids to 1000 mL/day.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

Staff have entered the patient's room without a mask.

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?

Swab the nasopharyngeal mucosa for cultures.

When assessing a 53-yr-old patient with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

The patient's blood pressure is 88/42 mm Hg.

Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink?

Transesophageal echocardiogram

An essential aspect of teaching that may prevent recurrence of heart failure is:

compliance with diuretic therapy.

the patient presents to the ED with severe chest discomfort. He is taken for cardiac catheterization and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed?

coronary artery bypass graft surgery

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as

decorticate posturing

A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers?

echocardiogram

A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications prior to admission for:

erectile dysfunction

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse?

implement droplet precautions upon admission.

Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery?

left main coronary artery

A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzymes (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process?

myocardial remodeling

A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient?

statins

The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia?

a-fib or a flutter


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