exam 3 ??
superifical burn
1st degree involves epidermis
superficial partial
2nd degree includes epidermis and part of the dermal layer
deep partial
3rd degree epidermis is lost, exposed dermis is not moist
full thicknes
4th degree involves all layers of skin, fat, muscle and nerve endings
3. schedule for a STAT CT scan of the head
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
1. administer a stool softener BID
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90
d. explain to the pt that this could be a common temp problem
A hospitalized pt with a C7 cord injury begins to yell "I cant feel my legs anymore." Which is the most appropriate action by the nurse a. Remind the pt of her injury and try to comfort her b. Call the HCP and get an order for raduologic eval c. Prepare the pt for surgery, as her condition is worsening d. Explain to the pt that this could be a common, temp problem
d. resp compromise
A nurse Is caring for a client who has C4 SCI, which of the following should the nurse recognize the client as being at greatest risk for? a. Neurogenic shock b. Paralytic ileus c. Stress ulcer d. Resp compromise
b. sit the client upright in bed
A nurse caring for a pt with SCI who resports severe headache and is sweating profusely. VS BP=220/110, apical; HR=54. Which of the following actions should the nurse take first? a. Notify the HCP b. Sit the client upright in bed c. Check the pts urinary cath for blockage d. Admin antihypertensive meds
a. condom cath
A nurse is caring for a pt who experienced a cerc SCI 3 months ago. Which of the following types of bladder management method should the nurse use for this client a. Condom cath b. Intermittent urinary cath c. Credes method d. Indwelling urinary cath
a. prevent of further damage to the spinal cord
A nurse planning care for a pt who suffered SCI involving T12 fracture 1 week ago. The client has no muscle control of the lower libs, bowel or bladder. Which of the following should be the nurses greatest priority a. Prevent of further damage to the spinal cord b. Prevention of contractures of the lower limbs c. Prevention of skin breakdown of areas that lack sensation d. Prevent of postural hypotenstion when placing the client in a wheelchair
b. kinked cath tube e. fecal impaction
A pt has manifestation of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition. SATA a. HTN b. Kinked cath tube c. Resp wheezes and stridor d. Diarrhea e. Fecal impaction
b. HR 42
A pt is admitted to the ER with SCI at T2. Which of the following findings is most concern to the nurse a. SpO2 92% b. HR 42 c. BP 88/60 d. Loss of motor sensory function in arms and legs
a. maintain a patent airway
A pt is admitted to the ER with possible cervical SCI following car crash. Durint the admission of the pt, the nurse places the highest priority on a. Maintain a patent airway b. Assessing the pt for head and other injuries c. Maintaining immobilization of cerv spine d. Assess the pts motor and sesory function
d. loss of SNS innervation resulting in peripheral vasodilation
A pt is admitted to the hospital with a C4 SCI after a motorcycle collision. The pts BP=83/49 and pulse=39 and he remains orally intubated. The nurse IDs this pathophysiologic response as caused by a. Increase vasomotor tone after injury b. A temp loss of sensation and flaccid paralysis below the level of injury c. Loss of parasympathetic nervous system innervation resulting in vasoconstriction d. Loss of SNS innervation resulting in peripheral vasodilation
d. exhaling during repositioning
A pt recovering from head injury is arousable and participating in care. The nurse determines that the pt understands measures to prevent elevated ICP if the nurse observes the client during which of the following activities a. Blowing the nose b. Isometric exercises c. Coughing vigorously d. Exhaling during repositioning
d. quadriplegia
A pt with SCI has complete paralysis of the upper extremitis and complete paralysis of the lower part of the body. The nurse should use which med term to adequately describe this in documentation? a. Hemiplegia b. Paresthesia c. Paraplegia d. Quadriplegia
c. resolution of spinal shock is manifested by spasticity, hyperreflexia and reflex emptying of the bladder
A pt with a SCI has spinal shock. The nurse plans care for th pt based on the knowledge that a. Rehab measures cannot be initiated until spinal shock has resolved b. The pt will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. Resolution of spinal shock is manifested by spasticity, hyperreflexia and reflex emptying of the bladder d. The pt will have complete loss of motor and sensory function below level of injury, but autonomic function are not affected
b. Assessing the pts skin integrity d. Admin pain meds e. Providing passive ROM
A pt with a SCI is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this pt? select all that apply a. Modifying the traction weights as needed b. Assessing the pts skin integrity c. Applying the traction upon admission d. Admin pain meds e. Providing passive ROM
a. autonomic dysreflexia
A pt with a SCI is recovering from spinal shock. The nurse realizes that the pt should not develop a ful bladder because of what emergency condition can occur if it is not corrected quickly? a. Autonomic dysreflexia b. Autonomic crisis c. Autonomic shutdown d. Autonomic failure
b. full function of the pts arms will be retrained
A pt with a T1 SCI is admitted to the ICU. Th enurse will teach the pt and family that a. Use of the shoulders will be persevered b. Full function of the pts arms will be retrained c. Total loss of resp function may occur temporarily d. Elevation in HR are common with this type of injury
d. flaccid paralysis and lack of sensation below the level of injury
A pt with a neck fracture at the C5 level is admitted to the ICU following initial treatment in the ER. During initial assessment of the pt, the nurse recognizes the presence of spinal shock on finding a. Hypotension, bradycardia and warm extremities b. Involuntary, spastic movements of the arms and legs c. The presence of hyperactive reflex activity below the level of injury d. Flaccid paralysis and lack of sensation below the level of injury
b. how to perform intermittent self cath
A pt with paraplegia has developed an irritable bladder with reflex emptying. The nurse teaches the pt a. Hygiene care for an indwelling cath b. How to perform intermittent self cath c. To empty bladder with manual pelvic pressure in coordination with reflex voiding patterns d. That a urinary diversion such as ileal condult is the easiest way to handle urinary elimination
c. infarction and necrosis of the cord caused by edema, hemorrhage and metabolites
An initial incomplete SCI often results in complete cord damage because of a. Edematous compression of the cord above the level of injury b. Continued trauma to the cord resulting from damage to stabilizing ligaments c. Infarction and necrosis of the cord caused by edema, hemorrhage and metabolites d. Mechanical transection of the cord by sharp vertebral bone frags after initial injury
a. Immobilize the necj using rolled towels or a cervical color b. The pt will be placed in a supine position e. The pts head will be secured with a belt or tape secured to the stretcher
An unconscious pt receiving emergency care following an automobile crash has a possible SCI. what guidelines for emergency care will be followed? SATA a. Immobilize the necj using rolled towels or a cervical color b. The pt will be placed in a supine position c. The pt will be placed on a vent d. The HOB will be elevated e. The pts head will be secured with a belt or tape secured to the stretcher
c. assess lung sounds and resp rate and depth
During assessment of a pt with a SCI, the nurse determines that the pt has a poor cough with diaphragmatic breathing. Based on this finding, the nurses first action should be to a. Initiate frequent turning and repositioning b. Use tracheal suctioning to remove secretions c. Assess lung sounds and resp rate and depth d. Prepare the pt for endotracheal intubation and mech vent
a. helps the pt understand tat working thru grief will be a lifelong process
During the pts process of grieving for the loses resulting from SCI, the nurse a. Helps the pt understand that working thru the grief will be a lifelong process b. Should assist the pt to move thru all stages of the mourning process to acceptance c. Lets the pt know that anger directed at the staff and family is not a positive coping mechanism d. Facilitates the grieving process so tat it is completed by the time the pt is discharged from rehab
d. seperates into concentric rings and test pos for gluose
Female pt has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is CSF if the fluid a. Is clear and tests neg for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Seperates into concentric rings and test pos for glucose
d. NG suctioning
Following a T2 SCI, the pt develops paralytic ileus. While this condition is present, the nurse anticipates that the pt will need a. IV fluids b. Tube feedings c. Parenteral nutrition d. NG suctioning
b. Feed self with hand devices c. Drive an electric wheelchair d. Assist with transfer activites e. Drive adapted van from wheelchair
Goals of rehab for th ept with C6 SCI include. SATA a. Stand erect with leg brace b. Feed self with hand devices c. Drive an electric wheelchair d. Assist with transfer activites e. Drive adapted van from wheelchair
1. no reflex activity below the waist
In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache 4. Hypotension and bradycardia.
d. will probably be unable to have either psychogenic or reflecogenic erections with no ejaculation or orgasms
In counseling pt with spinal cord lesions regarding sexual function, the urse advises a male pt with a complete lower motor neuron lesion that he a. Is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs b. May have uncontrolled reflex eretions, but that orgasm and ejaculation are usually not possible c. Has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm d. Will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgams
c. take the pts BP
Pt with C7 SCI undergoing rehab tells the nurse he must have the flu because he has a bad headache and nausea. The initial action of the nurse is to a. Call the HCP b. Check the pts temp c. Take the pts BP d. Elevate the HOB 90
2. the client is able to focus and stay on task for 10 minutes
The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance 4. The client will regain bowel and bladder control.
2. refer the client to the state rehabilitation commission
The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Injury Association (ASIA). 2. Refer the client to the state rehabilitation commission. 3. Ask the social worker about applying for disability. 4. Suggest that the client talk with his significant other about this concern.
4. complete a neuro assessment
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.
c. BP 106/82
The HCP has ordered IV dopamine for a pt in the ER with SCI. the nurse determines that the drug is having the desired effect when assessment finding include a. Pulse 68 b. Resp rate 24 c. BP 106/82 d. Temp 96.8
1. the client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes
The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. 2. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. 3. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. 4. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.
2. deep partial thickness
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.
3. carbidopa makes more levodopa available to the brain
The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.
2. difficulty swallowing and immobility
The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? 1. Masklike facies and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect. 4. Lack of arm swing and bradykinesia.
3. "i will schedule appointments late in the morning after his morning bath"
The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."
2. an intravenous osmotic diuretic
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.
1. purposeless movement in respose to painful stimuli
The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.
1. awaken the client q 2hr
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.
1. position the client to prevent shoulder adduction 3. encourage the client to move the affected side
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.
1. an oral anticoagulant med
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.
4. obtain a raised toilet seat for the clients bathroom
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.
1. replace fluids and electrolytes
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.
3. there is no eye activity when the cold caloric test if performed
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. There is no eye activity when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.
4. maintain an adequate airway
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.
1. encourage the clients family to bring favorite foods
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.
3. tell the client to remember that changes in lifestyle take time
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.
1. position the client with HOB elevated at intervals
The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.
4."are you uncomfortable in closed spaces"
The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2. "Are you allergic to any type of dairy products?" 3. "Have you eaten anything in the last eight (8) hours?" 4. "Are you uncomfortable in closed spaces?"
2. powerlessness
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.
3. "the graft will come from an animal, probably a pig"
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."
2. place the hand in cool water
The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.
33. assess for bladder distension
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.
2. instruct the client to report reddened or irritated skin areas
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.
3. test the drainage for presence of glucose
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 × 2 gauze under the nose to collect drainage.
4. adequate peripheral circulation to both feet ensured
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.
1. "this must be hard for you. you're feeling worthless"
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."
4. lower the HOB immediately
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client's vital signs are T 99.2˚F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.
1. high risk for infection
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.
3. the assistant places a hand under the clients right axilla to move up in bed
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently
1. feed the 69 yo client diagnosed with parkinsons disease who is having difficulty swallowing
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.
3. assess the clients airway
The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him.
4. offer 6 meals per day with a soft consistency
The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency.
1. monitor the pulse oximetry reading 3. encourage coughing and deep breathing 5. administer intravenous corticosteroids
The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.
4. masklike facies and a shuffling gait
The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.
3. the clients ABGs are pH 7.34, PaO2 98, PaCO2 38, HCO3 20
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.
2. paralysis of the right side of the body and ataxia
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.
2. administer stool softeners daily 3. ensure that pulse oximeter is higher than 93% 5 administer mild sedatives
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.
4. the clients urinary output is 50 mL in 2hrs
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4˚F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.
c. suction the airway every 2 hrs per standing order
The nurse is caring for a pt with increased ICP the nurse realizes that some nursing actions are contraindicated with increased ICP. Which nursing action should be avoided? a. Reposition the pt every 2 hrs b. Position the pt with the HOB elevated 30 degrees c. Suction the airway every 2hrs per standing orders d. Provde continuous oxygen as ordered
3. the 58 yo client diagnosed with parkinsons disease who is crying and worried about her facial appearance
The nurse is caring for clients on a medical-surgical floor. Which client should be assessed first? 1. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a "2" on a 1-to-10 scale. 2. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes. 3. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. 4. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.
3. the 45 yo client admitted with blunt trauma to the head after a motorcycle accident who has a glasgow coma scale score of 6
The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
2. the client may have rapid mood swings and become easily upset
The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.
b. the halo device will allow me to get out of bed
The nurse is educating a pt and the family about diff types of stabilization devices. Which statement by the pt indicates that the pt understands the benefit of using a halo fixation device instead of gardener-wells tongs a. I wil have less pain if I use the halo device b. The halo device will allow me to get out of bed c. I am less likely to get an infection with the halo device d. The halo device does not have to stay in place as long
4. stabilize the clients cervical spine
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.
4. refer the client to an OT for eval
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.
4. the client will be able to carry out ADL's
The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? 1. The client will experience periods of akinesia throughout the day. 2. The client will take the prescribed medications correctly. 3. The client will be able to enjoy a family outing with the spouse. 4. The client will be able to carry out activities of daily living.
b. head turned to the side
The nurse is positioning the female client with increased ICP. Which of the following positions would the nurse avoid a. Head midline b. Head turned to the side c. Neck in neutral position d. HOB elevated 30-45 degrees
1. the client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs
The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the chang;e-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.
4. fetal tissue transplantation
The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? 1. Sterotactic pallidotomy/thalamotomy. 2. Dopamine receptor agonist medication. 3. Physical therapy for muscle strengthening. 4. Fetal tissue transplantation.
2. clean the clients wounds, body, and hair daily
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.
d. use a logroll technique when moving the pt
The pt arrives in the ER for car crash, during which the car ran into a tree. The pt was not wearing a seat belt, and the windshield shattered. What action is most important for you to do a. Determin if th ept lost consciousness b. Assess the Glasgow coma scale score c. Obtain a set of vital signs d. Use a logroll technique when moving the pt
2. administer low-dose subcutaneous anticoagulant
The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.
2. a weak pulse, shallow respirations, and cool pale skin
The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.
b. weak pulse, shallow resp and cool pale skin
The resident in long term facility fell during the previous shift and has a laceration in the occipital area that has been closed with steri strips. Which s/s would warrant transferring the resident to ER a. A 4cm area of bright red drainage on the dressing b. A weak pulse, shallow resp and cool pale skin c. Pupils that are equal, react to light, and accommodate d. Complaints of a headache that resolves with meds
b. extent of your injury cannot be determined until secondary injury to the cord is resolved
Two days following a SCI, a pt asks continually about the extent of impairment that will result from the injury. The best response by the nurse is a. You will have more normal function when spinal shock resolves and the reflex arc returns b. The extent of your injury cannot be determined until the secondary injury to the cord is resolved c. When your condition is more stable, an MRI will be done that can reveal the extent of the cord damage d. Because long term rehab can affect the return of function it will be years before we can tell when the complete effect will be
b. that could be a really positive finding can you show me the movement
Week following a SCI at T2, a pt experiences movement in jis legs and tells the nurse he is recovering some function. The nurses best response to the pt is a. It is really still too soon to know if you will have a return of function b. The could be a really positive finding can you show me the movement c. That's wonderful. We will start exercising your legs more frequently now d. Im sorry, but the movement is only a reflex and does not indicate normal function
b. place the hands on the epigastric area and push upward when the pt coughs
When caring for a pt who had a C7 SCI 10 days ago and has a weak cough effort, bibasilary crackles and decreased breath sounds, the initial intervention by the nurse should be a. Admin O2 at 7-9 L/min with face mask b. Plave the hands on the epigastric area and push upward when the pt coughs c. Encourage the pt to use an incentive spirometer every 2 hrs during the day d. Suction the pts oral and pharyngeal airway
c. assess resp rate and depth
When caring for a pt who was admitted 24hrs previously with C5 SCI, which nursing action has the highest priority a. Continuous cardiac monitoring for brady cardia b. Admin of methylprednisolone infusion c. Assess rep rate and depth d. Application of pneumatic compression devices to both legs
3. a BP 220/120 mmHg
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.
1. a 55 yo AA male
Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.
3. memory deficits
Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.
1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 5. Administer antibiotics as prescribed.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed.
3. assist with bowel training by placing the client on the bedside commode
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.
a. 18 yo male with prior arrest for DUI
Which pt is at which pt is at highest risk for SCI a. 18 yo male with prior arrest for DUI b. 20 yo female with hx of substance abuse c. 50 yo female with osteoporosis d. 35 yo male who coaches a soccer team
c. elevated BP
While caring for the pt with SCI the nurse elevates the HOB, removes compression stockings, and continues to assess VS every 2-3 minutes while searching for the cause in order to prevent loss of consciousness or death. By practiving these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? a. Hypoxia b. Bradycardia c. Elevated BP d. Tachycardia
c. skeletal traction with skull tongs
Without serg stabilization, immobilization and traction of the pt with a cervical SCI most frequently requires the use of a. Kinetic beds b. Hard cervical collars c. Skeletal traction with skull tongs d. Sternal occipital mandibular immobilizer brace
