401 exam 3 practice questions

A male client who sustained a head injury is admitted to the hospital. The client is able to open his eyes to pain stimulus and to localize the pain, but the verbal response is found to be confused. What would his GCS be?

11

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the GCS should the nurse document?

3

The nurse uses the rule of nines to estimate the % of the burn surface area on a client who has burns covering the entires surface of both arms, the posterior trunk, the genitals, and the entire left leg. What is the percentage of burn injury for this client?

55

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. What information about burns should guide the nurse's plan of care? a. burns are extremely painful and disfiguring b. some grafting of the burned area is necessary c. pressure dressings and prolonged hydrotherapy are required d. spontaneous epithelial regeneration occurs within several weeks

d. spontaneous epithelial regeneration occurs within several weeks if there is no subsequent infection of the burned areas, wound healing should be uneventful

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing ICP? a. hypervigilance b. constricted pupils c. increased HR d. widening pulse pressure

d. widening pulse pressure pressure on the vital centers in the brains causes an increase in SBP, widening the difference between SBP and DBP

Which GCS indicates the client is in a coma? a. 6 b. 9 c. 12 d. 15

a. 6

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L and the K+ level is 3.0 mEq/L. The nurse notifies the PCP. Which prescription should the nurse be prepared to administer? a. add KCl to the existing IV LR solution b. add NaCl to the existing IV LR solution c. d/c IV NaCl w 20mEq KCl solution and replace with IV 5%D5w solution d. d/c IV 5%D5W with 40mEq KCl solution and replace with IV 5% D5W

a. add KCL to the existing IV LR solution

A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? SATA a. assisting with splitting the cast b. assessing UOP c. evaluating the pain on a scale d. applying splints to the injured part e. placing cold compresses to the affected area

a. assisting with splitting the cast b. assessing UOP c. evaluating the pain on a scale

Which type of burn/injury may cause a client to have a cervical spine injury? a. electrical burns b. chemical burns c. inhalation injury d. cold thermal injury

a. electrical burns intense electrical currents can fracture long bones and vertebrae

After reviewing the lab reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome. Which findings support the nurse's suspicion? SATA a. fat cells in the urine b. PaO2 value of 55mmHg c. hct value of 30% d. platelet count of 160,000 e. PT time of 12sec

a. fat cells in the urine b. PaO2 value of 58mmHg c. hct value of 30%

The nurse is caring for a client with a SCI. Which assessment findings alert the nurse that the client is developing AH/AD? a. hypertension and bradycardia b. flaccid paralysis and numbness c. absence of sweating and pyrexia d. escalating tachycardia and shock

a. hypertension and bradycardia these occur as a result of exaggerated autonomic responses. paralysis is related to transection

The nurse is caring for a client with a body surface injury of 55%. Which info will the nurse consider when planning care for this client? a. is prone to poor healing b/c of hypermetabolic state b. has a decreased risk of infection when in a hypermetabolic state c. needs a cool environment to decrease caloric need d. will need 20 cal/kg during the healing process

a. is prone to poor healing b/c of hypermetabolic state hypermetabolic state results in lipid and protein catabolism, which in turn can inhibit wound healing.

A client is brought by ambulance to the ED. The client's s/s are indicative of opioid overdose. What does the nurse expect the primary HCP to prescribe? a. naloxone b. methadone c. epinephrine d. amphetamine

a. naloxone naloxone is an opioid antagonist that displaces opioids from receptors in the brain, reversing respiratory depression.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sounds on exhalation. Which immediate action would be appropriate for the safe care of the client? SATA a. providing O2 immediately b. notifying the rapid response team c. considering it a normal observation d. initiating an IV line and beginning fluid replacement e. obtaining an ECG of the client

a. providing O2 immediately b. notifying the rapid response team initiate IV and start fluids after airway is patent

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is MOST appropriate? a. the epidermis is damaged b. the dermis is damaged partially c. the structures beneath the skin are destroyed d. both the epidermis and the dermis are destroyed

a. the epidermis is damaged SPT = epidermis DPT = entire epidermis and part of dermis FT = destroyed epidermis and dermis

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? SATA a. vomiting b. irritability c. hypotension d. increased respirations e. decreased level of consciousness

a. vomiting b. irritability e. decreased LOC Anorexia and N/V occur because of pressure on the brain. Increasing pressure on the vital centers of the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered LOC. BP will be increased and RR will be decreased (cushing's triad).

A client is receiving IV mannitol after sustaining a critical head injury. What assessment will the nurse perform that is specific to the safe admin of the medication? a. daily weights b. UOP hourly c. vitals q2h d. LOC q8h

b. UOP hourly osmotic diuretic - needs to be excreted by kidneys. hourly UOP to assess response to therapy

The nurse is caring for the victims of a snowstorm who have been exposed to cold temps. Which clients are at high risk of sustaining cold injuries? SATA a. a client who is dehydrated b. a client who is hypoglycemia c. a client who is on opioid medication d. a client who has been a heavy smoker for years e. a client who has been suffering from thyrotoxicosis

b. a client who is hypoglycemic c. a client who is on opioid meds d. a client who has been a heavy smoker for years hypoglycemia is a cause of hypothermia. meds that suppress shivering, such as opioids, can be a contributing factor for cold injury. smokers have an increased risk of cold related injury because of the vasoconstrictive effects of nicotine

A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? SATA a. splitting the cast in half b. applying cold compresses c. reducing the traction weight d. loosening the client's bandage e. elevating the extremity above heart level

b. applying cold compresses e. elevating the extremity above the heart could result in vasoconstriction and exacerbate compartment syndrome. could lower venous pressure and slow arterial perfusion

A client who survived a lightening strike is admitted to the emergency unit. Which interventions cold be beneficial for this client's condition? SATA a. admin of diphenhydramine b. applying spinal immobilization technique c. stabilization of ABC d. applying ice packs in the axillae and groin and on the neck and head e. rapid rewarming in a water bath at a temp range of 104-108F

b. applying spinal immobilization techniques c. stabilization of ABC applying spinal immobilization would reduce spinal cord injury pain. stabilization of ABC may be beneficial to prevent respiratory and cardiac arrest.

A client falls from a 2 story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern to the nurse? a. GCS of 8 b. bleeding from the ears c. pupils reactive to light d. depressed fontanel

b. bleeding from the ears indicates potential basilar skull fx and assists with diagnosing the location of the injury

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? SATA a. coughing b. burn odor c. smoky breath d. leathery skin e. cardiac arrest

b. burn odor d. leathery skin e. cardiac arrest a client with electrical burns may have assessment findings as listed above d/t hypovolemia and electrical disturbances. the others are findings r/t inhalational injuries

The nurse is reviewing the diagnostic reports of four clients with complications of fracture. Which client may be treated with a fasciotomy? a. ARDS b. compartment syndrome c. VTE d. FES

b. compartment syndrome

Which caring for a client who sustained severe head injury in a MVA, the nurse observes that the client is constantly passing urine and is dehydrated. What does the nurse suspect as the cause for the client's condition? a. decreased secretion of aldosterone b. decreased secretion of ADH c. decreased secretion of parathyroid hormone d. decreased secretion of atrial natriuretic peptide

b. decreased secretion of antidiuretic hormone The client sustained a head injury; therefor the nurse suspects that the cause of constant water loss through urine could be because of decreased ADH. DI is a complication of TBI where the posterior pituitary does not secrete ADH.

During the first 48h after a client as sustained a thermal injury, which conditions should the nurse assess for? a. hypokalemia and hyponatremia b. hyperkalemia and hyponatremia c. hypokalemia and hypernatremia d. hyperkalemia and hypernatremia

b. hyperkalemia and hyponatremia initial fluid shift of K+ out of cells and into extracellular space causing serum K+ to rise. Na+ deficit

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased ICP should the nurse monitor this client? a. nausea b. lethargy c. sunset eyes d. hyperthermia

b. lethargy lethargy is an early sign of a changing LOC. nausea is subjective. sunset eyes and hyperthermia are late signs

A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an avg of 1lb (0.5kg) of weight each day. Which action will the nurse most likely take based up the adjusted dietary plan? a. provide low-sodium milk b. provide high-protein drinks c. provide foods that are low in k+ d. provide 10% more cals in the form of fats

b. provide high-protein drinks calories!!!

A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare? a. enzymatic agents b. scissors and forceps c. autolytic semi-occlusive dressing d. continuous passive motion device

b. scissors and forceps physical removal or dirt, damaged or dead tissue, and cellular debris from a wound or burn so that infection is prevented and healing is promoted. Scissors, forceps, or scalpels may be used along with hydrotherapy.

The nurse is caring for a client who had a TBI with increased ICP. Which healthcare provider prescription should the nurse question? a. continue anticonvulsants b. teach isometric exercises c. continue osmotic diuretics d. keep head of bed at 30 degrees

b. teach isometric exercises isometric exercises increase the basal metabolic rate and ICP.

A client has sustained a spinal cord injury at the T2 level. The nurse assess for signs of AH/AD. What is the rationale for the nurse's assessment? a. the injury results in loss of the reflex arc b. the injury is above the 6th thoracic vertebra c. there has been partial transection of the cord d. there is flaccid paralysis of the lower extremities

b. the injury is above the 6th thoracic vertebra the T6 level is the sympathetic visceral outflow level. because the client's injury is above this level, AH/AD is expected

A nurse is monitoring a client who is having a CT scan of the brain with contrast. Which response indicated that the client is having a reaction of the contrast medium? a. pelvic warmth b. feeling flushed c. SOB d. salty taste in mouth

c. SOB anaphylaxis is manifested by respiratory distress, hypotension, and shock!

A worker is involved in an explosion of a steam pipe and receives a scalding burns to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which classification should the nurse use to describe these burns? a. eschar b. full-thickness c. deep partial-thickness d. superficial partial-thickness

c. deep partial-thickness in DPT burns, upper layers of the dermis, and injury to deeper portions of the dermis occur

A healthcare provider prescribes mannitol for a client with a head injury. The nurse concludes that the purpose of the medication is to relieve cerebral edema by which mechanism? a. decreasing the production of cerebrospinal fluid b. limiting the metabolic requirements of the brain c. drawing fluid from brain cells into the bloodstream d. preventing uncontrolled electrical discharges in the brain

c. drawing fluid from the brain cells into the bloodstream mannitol, an osmotic diuretic, pulls fluid from the white cells of the brain to relieve cerebral edema

The nurse uses the GCS to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the MOST concern? a. flexing b. localizing c. extending d. withdrawing

c. extending decerebrate (extension) posturing indicates severe brain injury. The only more serious response is total lack of response.

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed? a. assessing for crepitus b. assessing for bleeding c. maintaining a patent airway d. performing a nero assessment

c. maintaining a patent airway

A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the client? a. performing vagal maneuver b. performing valsalva maneuver c. performing jaw-thrust maneuver d. performing oculocephalic maneuver

c. performing jaw-thrust maneuver a way to ensure a patent airway while protecting the cervical spine

The nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent? a. colitis b. gastritis c. stress ulcer d. metabolic acidosis

c. stress ulcer h2 antagonists decrease acid production which is related to ulcers of the GI tract

A client sustains full-thickness and deep partial-thickness burns. The client asks, "what is the difference between my full-thickness and deep partial-thickness burns?" Which info will the nurse share with the client? a. FT burns extend into the subq tissue; DPT burns affect only the epidermis b. FT burns involve superficial layers of the epidermis; DPT burns extend through the epidermis c. FT burns extend through the epidermis and only part of the dermis; DPT burns extend into the subq tissue d. FT burns extend into the subq tissue; DPT burns extend through the epidermis and involve only part of the dermis

d. FT burns extend into the subq tissue; DPT burns extend through the dermis and involve only part of the dermis

A client's serum sodium is 123 mEq/L. Which prescription should the nurse question? a. provide pretzels as a snack daily b. restrict fluid intake to 1000mL per day c. assess neuro status q2h d. admin IVF of 1/2NS at 125mL/h

d. admin IVF of 1/2NS at 125mL/h 1/2NS is a hypotonic solution, which is contraindicated. Tx for hyponatremia can include restricting fluid intake and increasing sodium intake.

Which activity is performed when a client is bitten by a brown recluse spider? a. removal of the necrotic tissue b. elevating the affected extremity c. allowing complete rest to the client d. applying cold compresses over the site

d. applying cold compresses over the site apply cold compresses over the site intermittently until there is no further progression of the wound. necrotic tissue is removed after evaluating the wound. elevation is recommended, but is not the first action. the client is allowed to rest after ensuring the client is safe

A nurse ifs caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? a. hemorrhage b. hypovolemic shock c. gastrointestinal atony d. autonomic hyperreflexia

d. autonomic hyperreflexia medical emergency!!!

What would be the priority nursing intervention in a client with electric burns? a. gently removing the burned cloth b. wrapping the client in a dry clean sheet c. cooling the burns for no more than 10 minutes d. checking the airway, breathing, and circulation

d. checking the airway, breathing, and circulation electric burns may be large (>10% TBSA) and therefore the priority is to focus on ABCs. after ensuring ABCs, the nurse then cools the burns for no more than 10 minutes (preventing hypothermia), removes burned clothing (preventing further tissue damage), and lastly wraps the client in a dry clean sheet (preventing further contamination of the wound and to provide warmth).

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings? a. decorticate b. pronator drift c. babinski's sign d. decerebration

d. decerebration

What is the priority nursing intervention for a client bitten by a snake? a. sucking the bitten area b. offering alcohol to the client c. applying ice to the affected area d. immobilizing the effected extremity using a splint

d. immobilizing the effected extremity using a splint may limit the spread of venom; ice is ineffective and may worsen client's condition

A nurse caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of a burn injury? a. preventing pain b. managing leukopenia c. preventing infection d. managing fluid loss

d. managing fluid loss massive fluid shifts during the emergent (resuscitation) phase of burns