Med Surg 3 Exam 3

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? SATA a) headache b) dilated pupils c) tachycardia d) decorticate posturing e) hypotension

a) headache b) dilated pupils d) decorticate posturing

a nurse is caring for a patient who has disseminated intravascular coagulation (DIC). which of the following laboratory values indicates the patient's clotting factors are depleted? SATA a) platelets 100,000 b) fibrinogen 120 c) fibrin degradation products 4.3 d) d-dimer 0.03 e) sedimentation rate 38

a) platelets 100,000 b) fibrinogen 120 rationale: in DIC, platelet levels are decreased, causing clotting factors to become depleted. clotting times are increased, which raises the risk for fatal hemorrhage. fibrinogen levels are decreased causing clotting factors to become depleted. clotting times are increased, which raises the risk for fatal hemorrhage

a nurse is reviewing the laboratory results of a lumbar puncture (LP) for a patient who has manifestations of bacterial meningitis. which of the following findings should the nurse expect? a) elevated glucose b) elevated protein c) presence of RBCs d) presence of d-dimer

b) elevated protein rationale: a LP is a diagnostic test in which CSF is extracted for examination. manifestations of bacterial meningitis include increased protein in the CSF

a nurse is caring for a patient who has increased ICP and a new prescription for mannitol. for which of the following adverse effects should the nurse monitor? a) hyperglycemia b) hyponatremia c) hypervolemia d) oliguria

b) hyponatremia rationale: mannitol is a powerful osmotic diuretic. adverse effects include electrolyte imbalances, such as hyponatremia

a nurse is providing teaching to a patient who is scheduled for an EEG in the morning. which of the following pieces of information should the nurse share? a) you will feel some mild electrical sensations like static electricity b) do not eat or drink anything except water after midnight c) shampoo your hair before the procedure and don't use any styling products after d) it is common to have short term memory loss after the procedure

c) shampoo your hair before the procedure and don't use any styling products after rationale: for the electrodes to adhere to the scalp, the patient's hair needs to be clean and free of oil and hair care products

a nurse is providing teaching to a patient who has a history of tonic-clonic seizures and is scheduled for a standard EEG. which of the following instructions should the nurse include in the teaching? a) remain NPO 6-8 hrs prior to the EEG b) take a sedative the night prior to the EEG c) thoroughly shampoo her hair prior to the EEG d) sleep for at least 8 hrs during the night prior to the test

c) thoroughly shampoo her hair prior to the EEG rationale: hairsprays, oils, and other hair preparations interfere with recording results of the EEG

The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed? a) Prone with the head turned to the right side b) High-Fowler's position with the legs elevated c) Supine position with the head on two pillows d) Side-lying with the head elevated 30 degrees

d) Side-lying with the head elevated 30 degrees Rationale: To prevent increased intracranial pressure, the nurse should maintain the patient in the head-up position (no more than 30 degrees). Head elevation over 30 degrees may decrease cerebral perfusion pressure. Extreme neck flexion (head on two pillows) and hip flexion (high-Fowlers position) should be avoided. Head should remain midline.

a nurse is preparing a patient for an EEG. when the patient asks the nurse what this test does, which of the following responses should the nurse provide? a) an EEG measures the electrical signals to your brain from hearing, sight and touch b) an EEG measures the electrical activity in your muscles c) an EEG identifies the magnetic fields produced by electrical activity in your brain d) an EEG records the electrical activity of your brain cells

d) an EEG records the electrical activity of your brain cells rationale: an EEG measures brain waves via multiple electrodes attached to the scalp. an EEG provides information to the HCP that can identify seizure disorders, sleep disorders, inflammation, bleeding or migraine headaches

a nurse is triaging patients during a mass casualty event. which of the following labels should the nurse assign to a patient who has a head injury with fixed, dilated pupils? a) red tag b) yellow tag c) green tag d) black tag

d) black tag rationale: the nurse should assign a black tag to patients who are not expected to live and will be allowed to die naturally. dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and indicate severely increased intracranial pressure.

A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. which of the following risk factors for this disorder should the nurse include in the teaching? a) warfarin therapy for a-fib b) placental abruption c) systemic lupus erythematosus d) heparin therapy for deep-vein thrombosis

d) heparin therapy for deep-vein thrombosis rationale: the nurse should identify that a patient who is receiving heparin therapy for longer than 1 week is at increased risk for the development of HIT.

a nurse is caring for a patient who has as cerebral lesion and develops hyperthermia. which of the following areas of the patient's brain is affected? a) Wernicke's area b) cerebral cortex c) basal ganglia d) hypothalamus

d) hypothalamus rationale: the hypothalamus is responsible for the regulation of body temperature

A nurse in the ER has assessed a client's airway, breathing, and circulation following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? a) question the client's coworkers about the mechanism of injury b) check the client's pupil for equality and reaction to light c) measure the client's alertness using Glasgow Coma Scale d) immobilize the client's cervical spine

d) immobilize the client's cervical spine rationale: the greatest risk is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. therefore, after assessing the ABCs the highest priority is immobilizing the patient's neck with a cervical collar. a patient with head trauma may also have damage to the cervical spine.

a nurse is assessing a patient who has a high-thoracic spinal cord injury. the nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? a) flushing of lower extremities b) hypotension c) tachycardia d) report of a headache

d) report of a headace rationale: autonomic dysreflexia is a neurological emergency that can occur in patients who have a cervical or thoracic spinal cord injury above the level of T6. autonomic dysreflexia can be triggered by a full bladder or distended rectum. manifestations include a severe, throbbing headache, flushing of the face and neck, bradycardia, and extreme hypertension

a nurse is assessing a patient who is postop following a craniotomy and has a urine output of 600. the nurse suspects the patient has manifestations of diabetes insipidus (DI). which of the following laboratory values should the nurse plan to obtain to assess for DI? a) BUN b) blood glucose c) urine ketones d) specific gravity

d) specific gravity rationale: a low specific gravity (1.001 to 1.003) is a manifestation of DI

You are called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, what do you think you should do first? a) Turn the patient to the side. b) Start oxygen by mask at 6 L/min. c) Restrain the patient's arms and legs to prevent injury. d) Record the time sequence of the patient's movements and responses as they occur.

a) Turn the patient to the side Rationale: During the seizure, the nurse should maintain a patent airway, protect the patient's head, turn the patient to the side, loosen constrictive clothing, and ease the patient to the floor, if seated. The patient should not be restrained, and no objects should be placed in the mouth. After the seizure, the patient may require repositioning to open and maintain the airway, suctioning, and oxygen. When a seizure occurs, the nurse should carefully observe and record details of the event because diagnosis and subsequent treatment often rest solely on the seizure description.

a nurse is teaching a patient who has a new diagnosis of simple partial seizures about auras. which of the following statements by the patient indicates an understanding of the teaching? a) an aura is a sensory warning that a seizure is imminent b) an aura is a continuous seizure in which seizures occur in rapid succession c) an aura is a period of sleepiness following the seizure d) an aura is a brief LOC accompanied by staring

a) an aura is a sensory warning that a seizure is imminent rationale: the aura can be similar to a hallucination and involve any of the senses. the patient can report hearing bells, seeing lights or smelling an odor

a nurse is caring for a patient who has DIC. which of the following medications should the nurse anticipate administering? a) heparin b) vitamin K c) mefoxin d) simvastatin

a) heparin rationale: the nurse should identify that heparin can be administered to decrease the formation of microclots, which deplete clotting factors

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time? a) keep neck stabilized b) insert NG tube c) monitor pulse and BP frequently d) establish IV access and start IV fluid replacement

a) keep neck stabilized rationale: the greatest risk is permanent damage to the spinal cord if a cervical injury does exist. the priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out

during a neurological assessment, a nurse asks the patient to name all of his children, their ages and their birth dates. which of the following types of memory is the nurse testing? a) remote b) sensory c) immediate d) recall

a) remote rationale: the nurse tests remote or long-term memory by asking questions such as where and when the patient was born, his age, when he graduated, childrens names, ages and birthdates. should verify information later on with family or friends

a nurse is assessing a patient with a closed head injury who has received mannitol for manifestations of ICP. which of the following indicates that the medication is having a therapeutic effect? a) serum osmolarity is 310 b) pupils are dilated c) HR is 56 d) the patient is restless

a) serum osmolarity is 310 rationale: mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. a serum osmolarity of 310 is desired. a decreased in cerebral edema should result in a decrease in ICP.

a nurse is caring for a patient who has a TBI and assumes a decerebrate posture in response to noxious stimuli. which of the following reactions should the nurse anticipate when drawing a blood sample? a) the patient rigidly extends his arms b) the patient internally flexes his wrists c) the patient curls into a fetal position d) the patient internally rotates his legs

a) the patient rigidly extends his arms rationale: the patient who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. decerebrate posturing indicates a severe brain stem injury and late neurological decline

a nurse is assessing a patient who has sustained a recent head injury. which of the following findings should the nurse recognize as a manifestation of increased ICP? a) widened pulse pressure b) tachycardia c) periorbital edema d) decrease in urine output

a) widened pulse pressure rationale: a widening pulse pressure (difference between systolic and diastolic) is a manifestation of increased ICP. other manifestations include pupil changes, change in LOC, and nausea/vomiting

a patient with a head injury has an arterial BP of 92/50 and an ICP of 18. the nurse uses the assessments to calculate the cerebral perfusion pressure (CPP). how should the nurse interpret the results? a) CPP is so low that brain death is imminent b) CPP is low and the BP should be increased c) CPP is high and ICP should be reduced d) CPP is adequate for normal cerebral blood flow

b) CPP is low and the BP should be increased

a nurse is caring for a patient who has received sedation. when the nurse applies nailbed pressure, the patient withdraws his hand. the nurse should document this response as indicating which of the following? a) confusion b) arousal c) orientation d) attention

b) arousal rationale: the nurse should document that the patient is demonstrating some degree of arousal. withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation

The nurse should suspect brainstem damage in a child when which of the following clinical manifestations is present? a) intermittent decorticate posturing b) bilateral dilated, nonreactive pupils c) acetone odor of the breath d) deep and rapid breathing pattern

b) bilateral dilated, nonreactive pupils

a nurse in the ER is assessing a patient who sustained a fall off of a roof. which of the following findings should the nurse identify as an indication of a basilar skull fracture? a) depressed fracture of the forehead b) clear fluid coming from the nares c) motor loss on one side of the body d) bleeding from the top of the scalp

b) clear fluid coming from the nares rationale: CSF manifests as a clear fluid coming from the nares or ears indicating a basilar skull fracture

A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? SATA a) suction ET tube frequently b) decreased the noise level in the patient's room c) elevate head on two pillows d) administer a stool softener e) keep patient well hydrated

b) decrease the noise level in the patient's room d) administer a stool softener rationale: decreasing the noise level and restricting the number of people in the patient's room can help prevent increases in ICP. administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements which can increase ICP

a nurse is caring for a patient who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. after checking the patient's vital signs, which of the following actions should the nurse perform next? a) administer nifedipine b) place in high-fowler's position c) check for urinary retention d) check for a fecal impaction

b) place in high-fowler's position rationale: placing in high-fowler's position to decrease the BP and reduce the risk of end-organ damage from the sudden rise in BP

a nurse is providing discharge teaching to the family of a patient who has a new diagnosis of a seizure disorder. the nurse should instruct the patient's family to take which of the following actions first in the event of a seizure? a) reorient the patient b) protect the patient's head c) loosen constrictive clothing d) turn the patient onto his side

b) protect the patient's head rationale: the patient is at greatest risk for injury from hitting his head, therefore the first action is to protect the patient's head from injury

a nurse is caring for a patient who has a brainstem injury. which of the following physiological functions should the nurse monitor? a) understanding speech b) respiratory effort c) decision-making ability d) temperature control

b) respiratory effort rationale: the nurse should monitor the respiratory effort of a patient who has an injury to the brainstem. the medulla in the brainstem controls the respiratory center

a nurse is caring for a patient who begins to have a generalized tonic-clonic seizure while lying in bed. which of the following actions should the nurse take? a) insert an oral airway b) turn the patient onto a side c) restrict movement of patient's limbs d) place a pillow under the patient's head

b) turn the patient onto a side rationale: the nurse should turn the patient onto a side to protect the patient from aspiration

a nurse is preparing a patient for an EEG. which of the following pieces of information should the nurse share with the patient? a) expect the test to take about 3 hours b) you will begin by lying still with your eyes closed c) you will sleep for the duration of the procedure d) expect some mild electrical shocks during the test

b) you will begin by lying still with your eyes closed rationale: the patient will have to lie still in a reclining chair or bed and keep her eyes closed for the initial recording

A patient with a head injury has an arterial BP of 92/50 mm Hg and ICP of 18 mm Hg. The nurse uses the assessments to calculate the cerebral perfusion pressure (CPP). How should the nurse interpret the results? a. The CPP is so low that brain death is imminent. b. The CPP is low, and the BP should be increased. c. The CPP is high, and the ICP should be reduced. d. The CPP is adequate for normal cerebral blood flow.

b. The CPP is low, and the BP should be increased. rationale: The cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain. CPP is equal to the MAP minus the ICP (CPP = MAP - ICP). MAP = DBP + 1/3 (SBP-DBP) = 50 + 1/3 (92-50) = 64 mm HgCPP = MAP - ICP = 46 mm HgNormal CPP is 60 to 100 mm Hg. CPP <50 mm Hg is associated with ischemia and neuronal death. A CPP <30 mm Hg results in ischemia and is incompatible with life. It is critical to maintain MAP when ICP is elevated. A patient with a head injury may require a higher blood pressure, increasing MAP and CPP, to increase perfusion to the brain and prevent further tissue damage.

a nurse responds to a call from a PCA that a patient just had a seizure and is unconscious. which of the following assessments is the nurse's priority? a) measure vital signs b) perform a neurological exam c) check airway patency d) assess for injuries

c) check airway patency rationale: following the ABC framework, ensuring a patent airway would be priority

a nurse is caring for a patient who experienced a TBI. which of the following findings indicate that the patient is experiencing increased intracranial pressure? a) battle's sign b) periorbital edema c) dilated pupils d) halo sign

c) dilated pupils rationale: dilated pupils indicate that intracranial pressure is increasing. this finding should be reported to the HCP immediately

a nurse is assessing a patient and suspects the client is experiencing DIC. which of the following physical findings should the nurse anticipate? a) bradycardia b) hypertension c) epistaxis d) xerostomia

c) epistaxis rationale: the nurse should identify that epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC

a nurse is assessing a patient who recently experienced a head injury. which of the following findings should the nurse identify as an indication of short-term memory impairment a) inability to remember current age b) inability to count backward c) inability to locate eyeglasses d) inability to recall names of family members

c) inability to locate eyeglasses rationale: short term memory loss is manifested by an inability to recall events or actions that just occurred, such as where the patient recently placed her eyeglasses

a nurse is assessing a patient who has ICP and has received IV mannitol. which of the following findings indicates a therapeutic effect of this medication? a) decreased blood glucose b) decreased bronchospasms c) increased urine output d) increased temperature

c) increased urine output rationale: mannitol is an osmotic diuretic used to reduce ICP by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. increased urine output and decreased intracranial pressure are therapeutic effects of this medication.

a nurse is assessing a patient who was admitted to the facility for observation following a closed head injury. which of the following is the priority assessment the nurse should perform to determine a change in the neurological status? a) vital signs b) body posture c) level of consciousness d) examination of pupils

c) level of consciousness rationale: using the urgent vs nonurgent priority setting framework to consider urgent needs to be the priority because they pose more of a risk to the patient. a change in LOC can be the first indication of a change in neurologic status

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? a) glasgow coma scale b) cranial nerve function c) oxygen saturation d) pupillary response

c) oxygen saturation rationale: using the ABC framework, O2 saturation is the priority action. brain tissue can only survive without perfusion for 3 min before permanent damage occurs

an ER nurse is assessing a patient who has a new TBI. the nurse observes extension of the patient's arms and legs, pronation of the arms, and plantar flexion of the feet. which of the following actions is the nurse's priority? a) monitor urinary output b) administer an osmotic diuretic c) provide supplemental O2 d) initiate seizure precautions

c) provide supplemental O2 rationale: the first action the nurse should take is to provide oxygen. the patient might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death

during a neurological assessment, a nurse asks how the patient arrived at the appointment and with whom. which of the following types of memory is the nurse testing? a) remote b) immediate c) recall d) past

c) recall rationale: to test recall or recent memory, the nurse should ask the patient to provide details about how he arrived at the appointment and with whom. the nurse should also ask the patient to name any HCP he saw in the past few days

a nurse is caring for a patient who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). this increase in ICP is due to which of the following? a) decreased cerebral perfusion b) leakage of the cerebral spinal fluid c) rigid skull containing cranial contents d) brain herniated into the brainstem

c) rigid skull containing cranial contents rationale: the nurse should identify that the patient's rigid skull prevents expansion. an increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP.

a nurse is caring for a patient who is postop following a frontal craniotomy. the nurse should place the client in which of the following positions? a) Trendelenburg b) prone c) semi-fowlers d) sims'

c) semi-fowlers rationale: to prevent an increase in ICP the nurse should position the patient with his head midline and the HOB at 30 degrees. this positioning permits blood flow to the patient's brain while allowing venous drainage thereby decreasing the postoperative risk of increased intracranial pressure

A patient with increased ICP is positioned in a lateral position with the head of the bed elevated 30 degrees. The nurse evaluates a need for lowering the head of the bed when the patient experiences a. ptosis of the eyelid. b. unexpected vomiting. c. a decrease in motor functions. d. decreasing level of consciousness.

d. decreasing level of consciousness. rationale: Decreasing level of consciousness indicates increased intracranial pressure. Maintain the patient with increased ICP in the head-up position and prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Adjust the body position to decrease the ICP maximally and to improve the CPP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head via the valveless venous system through the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the CPP by lowering systemic BP. Careful evaluation of the effects of elevation of the head of the bed on both the ICP and the CPP is required. Position the bed so that it lowers the ICP while optimizing the CPP and other indices of cerebral oxygenation.