test

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1. Check cranial nerve functioning. 2.Determine the cause of the accident. 3.Draw blood for arterial blood gas analysis. 4.Perform a pulmonary wedge pressure measurement.

3 Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury.

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which should the nurse expect to note on assessment of the client? A. Skin atrophy B. Sunken eyes C. Drooping on 1 side of the face D. A rounded "moonlike" appearence to the face

D.

A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? A) MRI B) PET scan C) X-ray D) Ultrasound

a. CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure.

The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. A) Absence of pain response B) Apnea C) Coma D) Absence of brain stem reflexes E) Absence of deep tendon reflexes

b, c, d

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? A. Extent of intracranial bleeding. B. Sites of brain injury. C. Activity of the brain. D. Percent of functional brain tissue.

c.

The nurse is caring for a ventilated client with increased intracranial pressure following a motor vehicle accident. The nurse monitors the PaCO2 to ensure it remains between 30-35 mm Hg. Which of the following is an expected outcome at this range of PaCO2? Select all that apply. 1. Vasoconstriction of cerebral blood vessels 2. Decreased cerebral blood flow 3. Decreased intracranial pressure 4. Decerebrate posturing 5. Changes to sodium levels in CSF Sodium levels and PaCO2 are not directly rela

1, 2, 3

Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply. 1. Monitor vital signs. 2.Monitor neurological status. 3.Monitor the dressing for signs of infection. 4.Monitor for signs of increased intracranial pressure. 5.Drain cerebrospinal fluid when the intracranial pressure is elevated.

1, 2, 3, 4 Because a subarachnoid bolt is placed in the subarachnoid space, it is not capable of draining cerebrospinal fluid, which is produced in the ventricles.

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply 1. Fever 2.Seizures 3.Hypoxia 4.Ischemia 5.Hypotension 6.Increased intracranial pressure (ICP)

3, 4, 5, 6 Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1. GCS = 3 2.GCS = 6 3.GCS = 9 4.GCS = 11

3.

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1. Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia

3.

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? 1. Concussion 2.Skull fracture ' 3.Subdural hematoma 4.Epidural hematoma

4

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L Which prescriptions should the nurse anticipate receiving? Select all that apply. A. Initiate an infusion of 3% NaCl. B. Administer intravenous furosemide. C. Restrict fluids to 800 mL over 24 hours. D. Elevate the head of the bed to high-Fowler's. E. Elevate the head of the bed to high-Fowler's.

A, C, E.

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? A. A urinary output of 50 mL/hr B. A coagulation time of 5 minutes C.A heart rate that is 90 beats per minute and irregular DA blood urea nitrogen level of 20 mg/dL

C.

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? A. A platelet count of 200,000 mm3 B. A blood glucose level of 99 mg/dL C. A potassium (K+) level of 3.0 mEq/L D. A white blood cell (WBC) count of 6000 mm3

C.

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of Addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? A. Agitation B. Diaphoresis C. Restlessness D. Severe abdominal pain

D.

After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A. Quadriplegia with gross arm movement and diaphragmatic breathing. B. Quadriplegia and loss of respiratory function. C. Paraplegia with intercostal muscle loss. D. Loss of bowel and bladder control.

a. A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing

A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? A) Blood glucose B) Assessment of urine for blood C) Weight D) Oral temperature

a. Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out.

The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator

a. The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowlers position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.

d

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider? A) The patient will be unable to use a wheelchair. B) The patient will be unable to swallow food. C) The patient will be continent of urine, but incontinent of bowel. D) The patient will require full assistance for all aspects of elimination.

d. Patients with a lesion at C4 are fully dependent for elimination.

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Decreased urine output or oliguria B. Hypertension and bradycardia C. Respiratory depression D. Symptoms of shock

b.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed. 2.Placing an airway at the bedside. 3.Placing the bed in the high position. 4.Putting a padded tongue blade at the head of the bed. 5.Placing oxygen and suction equipment at the bedside. 6.Flushing the intravenous catheter to ensure that the site is patent.

1, 2, 5, 6

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

1,2,3

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1. Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway 4.Disconnection or leak in the system 5.The client ceasing spontaneous breathing

1,2,3

The nurse has the following prescription for a postcraniotomy client: "dexamethasone 4 mg by the intravenous (IV) route now." How does the nurse administer the medication? 1.IV push over 1 minute 2.IV push over 4 minutes 3.IV piggyback in 100 mL of normal saline over 10 minutes 4.IV piggyback in 100 mL of normal saline over 30 minutes

1. Dexamethasone is an adrenocorticosteroid administered after craniotomy to control cerebral edema. It is given by IV push, and single doses are administered over 1 minute. D

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1. Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury

2. Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception.

The nurse has a prescription to give dexamethasone by the intravenous (IV) route to a client with cerebral edema. How should the nurse prepare this medication? 1.Diluting the medication in 500 mL of 5% dextrose 2.Preparing an undiluted direct injection of the medication 3.Diluting the medication in 1 mL of lactated Ringer's solution for direct injection 4.Diluting the medication in 10% dextrose in water and administering it as a direct injection

2 Dexamethasone may be given by direct IV injection or IV infusion. For IV infusion, it may be mixed with 50 to 100 mL of 0.9% sodium chloride or 5% dextrose in wate

The client with a traumatic brain injury (TBI) has begun excreting copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 mL. The nurse expects that the primary health care provider will prescribe which medication? 1. Mannitol 2.Desmopressin 3.Ethacrynic acid 4.Dexamethasone

2 Urine output that exceeds 9 L per day generally requires treatment with desmopressin.

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? 1.Normal 2.Abnormal 3.Insignificant 4.Inconclusive

2. Abnormal responses include movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned.

A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? 1. It will cause arteriovenous shunting. 2.It will cause vasodilation of blood vessels in the brain. 3.It will cause blood vessels in the circle of Willis to collapse. 4.It will cause hyperresponsiveness of blood vessels in the brain.

2. CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness.

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1. "When did the injury occur?" 2."Was the client awake and talking right after the injury?" 3."What medications has the client received since the fall?" 4."What was the client's level of consciousness before the injury?

2. Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase.

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that family members need further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom? 1. Vomiting 2.Minor headache 3.Difficulty speaking 4.Difficulty awakening

2. the family is taught to monitor the client and call the PHCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm? 1. Shut the alarm off and call for help. 2.Call the respiratory therapy department to fix the problem. 3.Call the primary health care provider (PHCP) for further instructions. 4.Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.

4

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1. Brain death 2.A cerebral lesion 3.A temporal lesion 4.An intact brainstem

4. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal normal is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1.Excessive secretions 2.Kinks in the ventilator tubing 3.The presence of a mucous plug 4.Displacement of the endotracheal tube

4. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

Absence of reflexes along with flaccid extremities. During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities. A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale . This allows the nurse to gauge what aspect of the patient's status Level of consciousness?

The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply. A) Epistaxis B) Pallor C) Rapid respiratory rate D) Bounding pulse E) Hypotension

b, c, e The patient at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock

Following an addisonian crisis, a patients adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances? A) Episodes of high psychosocial stress B) Periods of dehydration C) Episodes of physical exertion D) Administration of a vaccine

a During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. Physical activity, dehydration and vaccine administration would not normally be sufficiently demanding such to require glucocorticoids.

A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?a.Vigilant monitoring of fluid balance b. Continuous BP monitoring- c. Serial arterial blood gases (ABGs) d.Monitoring of the patient's airway for patency

a.

The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?a.Solumedrol- b.Dextromethorphan- c.Dexamethasone d.Furosemide

c. If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor.

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1. Thalamus 2.Hypothalamus 3.Limbic system 4.Reticular activating system

2. The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others).

The nurse is planning discharge teaching for a client started on acetazolamide for a supratentorial lesion. Which information about the primary action of the medication should be included in the client's education? 1. It will prevent hypertension. 2.It will prevent hyperthermia. 3.It decreases cerebrospinal fluid production. 4.It maintains adequate blood pressure for cerebral perfusion.

3. Acetazolamide is a carbonic anhydrase inhibitor and a diuretic. It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production.

The nurse is providing instructions to a client with a diagnosis of Addison's disease regarding the administration of prescribed glucocorticoids. The nurse should provide which instruction to the client? 1.To stop the medication if side effects occur 2.To avoid taking the medication if nausea occurs 3.That minimal side effects will occur with use of this medication 4.That an increased dose of medication may be needed during times of stress

4

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

c. Hyperventilation causes hypocapnia, which causes vasoconstriction, thus decreasing cerebral blood flow. H

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

d. The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema.

A primary health care provider (PHCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? 1. "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." 2."A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." 3."It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts." 4."It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time."

1. IMV/SIMV is 1 of the methods used for weaning. With this method, the respiratory rate is gradually decreased until the client assumes all of the work of breathing on his or her own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4 Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1.Take and record vital signs every 4 to 8 hours. 2.Prophylactically hyperventilate during the first 24 hours. 3.Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4. Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure.

a client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

After a hypophysectomy, vasopressin is given IM for which of the following reasons? A. To treat growth failure. B. To prevent syndrome of inappropriate antidiuretic hormone (SIADH). C. To reduce cerebral edema and lower intracranial pressure. D. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

After hypophysectomy or removal of the pituitary gland, the body can't synthesize ADH

A client has been pronounced brain dead. Which findings would the nurse assess? Select all that apply. A. Decerebrate posturing B. Dilated nonreactive pupils C. Deep tendon reflexes D. Absent corneal reflex

B,D

The nurse is caring for a patient with a diagnosis of Addisons disease. What sign or symptom is most closely associated with this health problem? A) Truncal obesity B) Hypertension C) Muscle weakness D) Moon face

c

A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? A. Subdural hematoma B. Subarachnoid hemorrhage C. Epidural hematoma D. Contusion

c.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis

c.

A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A) Glucose in the urine B) Albumin in the urine C) Highly dilute urine D) Leukocytes in the urine

c.

the nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 1. Use of the head tilt-chin lift 2.Checking the scene for safety 3.Use of the jaw thrust maneuver 4.Moving the client away from a busy traffic road

1 Whenever a neck injury is suspected, the jaw thrust maneuver should be used during basic life support (BLS) to open the airway. The head tilt-chin lift produces hyperextension of the neck and could cause complications if a neck injury is present.

The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply. 1.Reduced ICP 2.Increased diuresis 3.Increased osmotic pressure of glomerular filtrate 4.Reduced tubular reabsorption of water and solutes 5.Reabsorption of sodium and water in the loop of Henle

1, 2, 3, 4

The nurse is observing a new nursing graduate who is preparing an intermittent intravenous (IV) infusion of phenytoin for a client with a diagnosis of seizures. Which solution used by the nursing graduate should indicate to the nurse an understanding of proper preparation of this medication? 1.5% dextrose in water 2.0.9% sodium chloride 3.Lactated Ringer's solution 4.5% dextrose and 0.45% sodium chloride

2. Intermittent IV infusion of phenytoin is administered by injection into a large vein, using normal saline solution.

A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner? 1.Mixed in solution with the IV antibiotics 2.Giving it slowly over 30 to 90 minutes 3.Piggybacked into the packed red blood cells 4.Giving it rapidly over 5 minutes by IV bolus

2. Mannitol is an osmotic diuretic. When used to treat increased ICP, it is given slowly over 30 to 90 minutes, not rapidly and not via IV bolus.

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

4. The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg).

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

A, B, D, E

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply A. Daily weights B. I+Os C. Assess extremities for edema D. Maintain a high potassium diet E. Maintain a low-potassium diet

A,B,C

A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patients nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply. A) Foods high in vitamin D B) Foods high in calories C) Foods high in protein D) Foods high in calcium E) Foods high in sodium

A,C,D Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the patient in selecting appropriate foods that are also low in sodium and calories

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

a

The nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk? A) Establish falls prevention measures. B) Encourage bed rest whenever possible. C) Encourage the use of assistive devices. D) Provide constant supervision.

a The nurse should take action to prevent the patients risk for falls.

A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patients nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply. A) Foods high in vitamin D B) Foods high in calories C) Foods high in protein D) Foods high in calcium E) Foods high in sodium

a, c, d Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis

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

a.

A client who 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.

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinskis reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

a.

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: A. desmopressin (DDAVP, Stimate) B. Dexamethasone (Decadron) B. Dexamethasone (Decadron) C. ethacrynic acid (Edecrin) D. mannitol (Osmitrol)

a.

The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)

a.

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer? A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel. B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state. C) Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing. D) The sudden, severe headache increases muscle tone and can cause further nerve damage.

a.

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

a.

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea

a. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

Which of the following respiratory patterns indicate increasing ICP in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest expansion D. Nasal flaring

a. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. R

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patients indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C)Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

a. A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

a. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve.

A client with head trauma develops a urine output of 300 ml/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. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the antidiuretic hormone. This may occur with increased intracranial pressure and head trauma;

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A.Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

b

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

b

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patients BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

b

The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? A) Temperature and oxygen saturation B) Heart rate and BP C) Breath sounds and bowel sounds D) Color, warmth, movement, and sensation of extremities

b The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours.The patients condition needs to be monitored frequently during , and the test is terminated if tachycardia, excessive weight loss, or hypotension develops.

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? A. Bloody drainage from the ears B. Frequent swallowing C. Guaiac-positive stools D. Hematuria

b.

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

b.

the patient about hormone replacement therapy, the nurse should address what topic? A) The possibility of precipitous weight gain B) The need for lifelong steroid replacement Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 980 C) The need to match the daily steroid dose to immediate symptoms D) The importance of monitoring liver function

b.

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A. Position the client flat in bed. B. Check the fluid for dextrose with a dipstick. C. Suction the nose to maintain airway patency. D. Insert nasal and ear packing with sterile gauze.

b. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose.

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: A. A flattened abdomen. B. Hematest positive nasogastric tube drainage. C. Hyperactive bowel sounds. D. A history of diarrhea.

b. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool.

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

b. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias.

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A. To hasten wound healing. B. To immobilize the cervical spine. C. To prevent autonomic dysreflexia. D. To hold bony fragments of the skull together.

b. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage. B. Schedule intermittent catheterization every 2 to 4 hours. C. Perform a straight catheterization every 8 hours while awake. D. Perform Crede's maneuver to the lower abdomen before the client voids.

b. Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours

A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart? A) When the patients condition begins to deteriorate B) As soon as the initial assessment is made C) At the beginning of each shift D) When there is a clinically significant change in the patients condition

b. Neurologic parameters are assessed initially and as frequently as the patients condition requires. As soon as the initial assessment is made, the use of a neurologic flowchart is started and maintained. A new chart is not begun at the start of every shift.

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, the return of reflexes, is a sign of resolving shock

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Limiting bladder catheterization to once every 12 hours. C. Keeping the linen wrinkle-free under the client. D. Preventing unnecessary pressure on the lower limbs.

b. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? A. "Watch him for a keyhole pupil the next 24 hours." B. "Expect profuse vomiting for 24 hours after the injury." C. "Wake him every hour and assess his orientation to person, time, and place." D. "Notify the physician immediately if he has a headache."

c.

The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? A. Monitoring vital signs before and during position changes. B. Using vasopressor medications as prescribed. C. Moving the client quickly as one unit. D. Applying Teds or compression stockings.

c.

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?

c.

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

c. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary.

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A) Epistaxis B) Periorbital edema C) Bruising over the mastoid D) Unilateral facial numbness

c. An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture

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

c. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A. acetazolamide (Diamox) B. furosemide (Lasix) C. methylprednisolone (Solu-Medrol) D. sodium bicarbonate

c. High doses of methylprednisolone are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit.

A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? A. By inserting a nasopharyngeal airway. B. By inserting an oropharyngeal airway. C. By performing a jaw thrust maneuver. D. By performing the head-tilt, chin-lift maneuver.

c. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway.

Paramedics have brought an intubated patient to the RD following a head injury due to accelerationdeceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A) Keep the head of the bed (HOB) flat at all times. B) Teach the patient to perform the Valsalva maneuver. C) Administer benzodiazepines on a PRN basis. D) Perform endotracheal suctioning every hour.

c. If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

c. In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski's reflex. D. Reflex emptying of the bladder.

c. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.

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

c. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion.

A patient with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this patient? A) Increased body temperature B) Jaundice C) Copious urine output D) Decreased BP

d

A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following? A) Take the drug concurrent with levothyroxine (Synthroid). B) Take each dose of prednisone with a dose of calcium chloride. C) Gradually replace the prednisone with an OTC alternative. D) Slowly taper down the dose of prednisone, as ordered.

d Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency.

A patient with pheochromocytoma has been admitted for an adrenalectomy to be performed the following day. To prevent complications, the nurse should anticipate preoperative administration of Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 991 which of the following? A) IV antibiotics B) Oral antihypertensives C) Parenteral nutrition D) IV corticosteroids

d IV administration of corticosteroids (methylprednisolone may begin on the evening before surgery and continue during the early postoperative period to prevent adrenal insufficiency.

A patient with pheochromocytoma has been admitted for an adrenalectomy to be performed the following day. To prevent complications, the nurse should anticipate preoperative administration of Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 991 which of the following? A) IV antibiotics B) Oral antihypertensives C) Parenteral nutrition D) IV corticosteroids

d IV administration of corticosteroids (methylprednisolone sodium succinate [Solu-Medrol]) may begin on the evening before surgery and continue during the early postoperative period to prevent adrenal insufficiency.

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupil D. Decrease in LOC

d.

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A. Elevate the client's legs. B. Put the client flat in bed. C. Put the client in Trendelenburg's position. D. Put the client in the high-Fowler's position.

d.

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: A. Skull fracture B. Concussion C. Subdural hematoma D. Epidural hematoma

d.

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

d.

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

d. Noxious stimuli, such as a full bladder, fecal impaction, or a decubitus ulcer, may cause autonomic dysreflexia.

A patient on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks duration can suppress the adrenal cortex for how long? A) Up to 4 weeks B) Up to 3 months C) Up to 9 months D) Up to 1 year

d. Suppression of the adrenal cortex may persist up to 1 year after a course of corticosteroids of only 2 weeks duration

A client with a C6 spinal injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Tetraplegia

d. Tetraplegia occurs as a result of cervical spine injuries. Cervical injuries lead to the same deficits as thoracic injuries and, also, may result in loss of function of the upper extremities leading to tetraplegia.