Acute Care Test 2

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client?

Absolute bed rest in a quiet, non-stimulating environment

23-year-old male in a diving accident and admitted unconscious. His BP, pulse, and respirations are all low and his breaths are shallow. A CT scan shows a massive subdural hematoma. What should the nurse get prepared for to do immediately for this patient?

Activate rapid response, maintain ABCs, initiate neurological assessments, prepare for surgery, continuous monitoring (pulse, ECG)

A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?

Ask if he would like you to sit with him while he collects his thoughts.

A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patient's disease?

Follow the trends of the patient's hematocrit.

NGN- 2 day history of lethargy, nausea, vomiting, sore throat, etc.

Gastroenteritis Actions: Supportive care, isolate the client Monitor: Temperature, symptom improvement

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best?

Give the client pain medication if it is time for another dose.

23-year-old male in a diving accident and admitted unconscious. His BP, pulse, and respirations are all low and his breaths are shallow. The nurse recognizes that these vitals are due to what cause?

Hypoxia or reduced oxygen levels

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

A nurse practitioner is assessing a client who has a fever, malaise, and a white blood cell count that is elevated. What principle should guide the nurse's management of the client's care?

Infection is the most likely cause of the client's change in health status.

The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client?

Initiate an intravenous (IV) line for the administration of fluids.

A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?

Meningitis

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?

Perform passive ROM exercises as ordered.

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.

B. Recent intracranial pathology C. Current anticoagulation therapy D. Symptom onset greater than 3 hours prior to admission

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply.

B. Understanding of the tests used to diagnose neurologic disorders C. Knowledge of nursing interventions related to assessment and diagnostic testing D. Knowledge of the anatomy of the nervous system

A patient has suffered a stroke due to disruption of flow in the basilar artery. Which of the following is the most likely presentation in the patient?

Balance problems and vertigo

A patient has a platelet count of 25,000/mm3 (25 × 109/L). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

C) Help the patient choose soft foods from the menu. D) Shave the male patient with an electric razor. E) Use a lift sheet when needed to reposition the patient.

CPP formula

CPP = MAP - ICP

A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be aware of what main goal of care?

Cure of the disease

Early signs of increased intracranial pressure (ICP) include headache, confusion, vomiting and which of the following?

Decreased level of consciousness

A patient has thrombocytopenia. What patient statement indicates that the patient understands self-management of this condition?

"I usually put ice on bumps or bruises."

Which questions does the nurse ask when conducting an expanded assessment to determine patient orientation? Select all that apply.

"What is your name" "What is today's date" "What kind of place are we in right now"

Key features of increased ICP

-Decreased LOC (Lethargy to Coma) -Behavior changes: restless, irritable, and confused -Headache -Nausea and vomiting -Change in speech pattern -Aphasia -Slurred speech -Change in sensorimotor status

A nurse is suspecting that a patient is experiencing an ischemic stroke of the basilar artery. what manifestations did the nurse most likely assess in this patient?

-Vertigo/dizziness -Dysarthria (impaired speech) -Facial weakness -Dysphagia -Ataxia (lack of coordination) -Confusion -Nausea and vomiting -Impaired respiratory function

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 health care provider 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

Ischemic cascade

1. Small core area in brain that receives less than 20% of normal blood flow 2. Transitional zone (around core) receives 20-50% 3. Once stroke starts, small core area brain cells die; release toxic chemicals that position and kill cells in transitional zone (can be saved) 4. The longer it takes to get to the hospital, the more damage is done

Steps of hemostasis (blood clotting)

1. Vascular phase- constrict to slow blood loss 2. Platelet phase- platelets form a plug 3. Coagulation phase- enzymatic process with clotting factors 4. Clot retraction and repair- platelets pull on fibrin making them contract 5. Fibrinolysis- clot is broken down by plasmin after repair

An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC?

A patient who is being treated for septic shock

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?

A positive Brudzinski's sign

During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.

A) National Institutes of Health Stroke Scale (NIHSS) score C) LOC at time of admission E) Age

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.

A) Young age D) Male gender E) Alcohol and drug use

The nurse would recognize which signs and symptoms as consistent with brain stem tumors? (Select all that apply.)

A. Hearing loss B. Facial pain C. Nystagmus (involuntary eye movement)

An oncology nurse recognizes a client's risk for fluid imbalance while the client is undergoing treatment for leukemia. What related assessments should the nurse include in the client's plan of care? Select all that apply.

A. Monitoring the client's electrolyte levels C. Measuring the client's weight on a daily basis D. Measuring and recording the client's intake and output E. Auscultating the client's lungs frequently

A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patients care plan?

Protective isolation and vigilant use of standard precautions

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication?

Provide a board of commonly used needs and phrases.

A carotid endarterectomy patient arrives to you in the PACU. What initial assessment is MOST important?

Pupil checks

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?

The client should be approached on the side where visual perception is intact

An oncology nurse is providing health education for a client who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia?

The different leukemias all involve unregulated proliferation of white blood cells.

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply.

Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Provide ample time for the client to chew and swallow

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke?

White male, age 60, with history of uncontrolled hypertension

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)

a. Alcohol intake c. High-fat diet d. Obesity e. Smoking

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.)

a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion d. Using gloves to start the client's IV if needed and to handle the blood product