NURS 482 - Final Exam Practice Questions (Module 5-7)

A client presents to the emergency department with a thoracic level T5 spinal cord injury. The nurse is concerned about neurogenic shock. Which of the following are considered hallmark signs of neurogenic shock? hypotension and tachycardia hypertension and bradycardia hypertension and tachycardia hypotension and bradycardia

hypotension and bradycardia Neurogenic shock is caused by loss of communication with the sympathetic nervous system resulting in loss of vascular tone and causes hypotension and bradycardia.

What are the normal levels of Phenytoin?

10 to 20 mcg/mL

What is the GCS for a 40-year-old man brought in dead after an MVC by the rescue paramedics?

3 eyes = 1, motor = 1, verbal = 1

What is the GCS for an 18-year-old woman s/p MVC in a "coma"?

8

Which of the following side effects are possible for a patient taking an anti-thyroid medication? A. Agranulocytosis and aplastic anemia B. Tachycardia C. Skin discoloration D. Joint pain and eczema

A. Agranulocytosis and aplastic anemia

A patient taking Tapazole reports feeling dizzy, intolerant to cold, and tired. On assessment, you note the patient's heart rate is 45 and blood pressure is 70/30. What is the most likely cause? A. Antithyroid toxicity B. Agranulocytosis C. Thyroid storm D. Bronchospasm

A. Antithyroid toxicity The patient may be experiencing antithyroid toxicity (too much of the antithyroid medication). This will causes signs and symptoms of hypothyroidism which can lead to a myxedema coma, if not treated immediately.

Which of the following are treatment options for hyperthyroidism? Please select all that apply: A. Thyroidectomy B. Methimazole C. Liothyronine Sodium "Cytomel" D. Radioactive Iodine

A. Thyroidectomy B. Methimazole D. Radioactive Iodine Liothyronine Sodium "Cytomel" is a treatment for hypothyroidism. All the other options are for hyperthyroidism.

Which of the following insulins can be administered intravenously? A. NPH B. Lantus C. Humulin R D. Novolog

C. Humulin R

What type of insulin do you expect the doctor to order for treatment of DKA? IV Novolog IV Levemir IV NPH IV Regular Insulin

IV Regular Insulin

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.

Maintain an adequate airway. The most important nursing goal in the management of a client with a head injury is to establish and maintain adequate airway.

What are the responses/scores included in the Glasgow Coma Scale for the Best Motor Response assessment?

Obeys commands = 6 Localizes pain = 5 Flexion withdraw = 4 Abnormal flexion = 3 Abnormal extension = 2 No response = 1

Which of the following is not a sign or symptom of Diabetic Ketoacidosis? Positive Ketones in the urine Oliguria Polydipsia Abdominal Pain

Oliguria means low urinary output....in DKA you have high urinary output (POLYURIA).

What are the responses/scores included in the Glasgow Coma Scale for the Best Verbal Response assessment?

Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible sounds = 2 No response = 1

A patient with meningitis is drowsy and confused. What should the nurse explain to the patient's family as being the cause for these mental status changes? Decreased intracranial pressure Bleeding in the central nervous system Elevated serum white blood cell count Sluggish flow of cerebrospinal fluid

Sluggish flow of cerebrospinal fluid Rationale: Pathogen entry into the CNS initiates the inflammatory response in the meninges, CSF, and ventricles. Meningeal vessels become engorged and permeability increases. Phagocytic white blood cells migrate into the subarachnoid space, forming a purulent exudate that thickens and clouds the CSF and impairs its flow. Intracranial pressure can increase and not decrease with meningitis. Meningitis does not cause bleeding into the central nervous system. An elevated systemic white blood cell count does not affect the cognitive status.

What are the responses/scores included in the Glasgow Coma Scale for the Eyes Open assessment?

Spontaneously = 4 To speech = 3 To pain = 2 No response = 1

A patient reports narrowly missing having an automobile crash while merging onto the freeway while driving to see the healthcare provider for a routine appointment. Which division of the autonomic nervous system should the nurse recall as causing body responses to stress? Adrenergic Cholinergic Sympathetic Parasympathetic

Sympathetic Rationale: The sympathetic division of the ANS has the purpose of preparing the body to handle stressful events, such as almost being in an automobile crash, by increasing heart rate, force of contraction, vasodilation of coronary arteries, and increased mental alertness. The parasympathetic division of the ANS operates during non-stressful situations and causes pupil constriction, decreased heart rate, vasoconstriction of coronary arteries, constriction of the bronchioles, and increased peristalsis. Adrenergic is a term used to describe the effects of the neurotransmitter norepinephrine. Nerves that transmit impulses through the release of acetylcholine are called cholinergic.

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. The clients head is turned to the right, the eyes turn to the right. 2. The 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.

There is no eye activity when the cold caloric test is performed The cold caloric test, also called the ocular vestibular test, is used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client eyes moved, that would indicate that the brainstem is intact.

The nurse is planning to assess a patient's gag reflex. What equipment should the nurse use to test this reflex? Safety pin Cotton ball Stethoscope Tongue depressor

Tongue depressor Rationale: The gag reflex is assessed by touching the back of the patient's throat with a tongue depressor. A safety pin is used to assess fine touch. A cotton ball is used to assess fine touch and the corneal reflex. A stethoscope is not used during the assessment of the neurologic system.

True or False: Osmotic diuresis is present in HHNS and DKA due to the kidney's inability to reabsorb the excessive glucose which causes glucose to leak into the urine which in turn causes extra water and electrolytes to be excreted.

True

True or False: Treatment of Hyperglycemic Hyperosmolar Nonketotic Syndrome is similar to the treatment of Diabetic Ketoacidosis.

True

True of False: Traumatic brain injury could lead to bacterial (not viral) meningitis?

True Traumatic brain injury could lead to bacterial (not viral) meningitis. Nosocomial bacterial meningitis is the result of the manipulation of the meninges during neurosurgical procedures. Invasion of bacteria into the subarachnoid space results in inflammation of the meninges.

A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition? "I should not be alarmed if ketones are present in my urine because this is expected during illness." "It is normal for my blood sugar to be 250-350 mg/dL while I'm sick." "I will hold off taking my insulin while I'm sick." "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."

"It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."

The nurse is monitoring the neurologic status of a patient in a coma. Which command should the nurse use to accurately identify changes in mental status? "Squeeze my hand." "Tell me your name." "Are you having trouble breathing?" "Look at this light when I shine it in your eyes."

"Squeeze my hand." Rationale: The level of brain dysfunction and the side of the brain affected may be assessed by motor responses. These responses are the most accurate identifier of changes in mental status. In altered LOC, asking the patient to "squeeze my hand" would be used to determine mental status changes. Other questions such as "Tell me your name," "Are you having trouble breathing?" and "Look at the light while it is shined in your eyes" will not accurately determine mental status changes in the patient.

A patient is being discharged home after recovering from HHNS. Which statement by the patient requires patient re-education about this condition? "I will monitor my blood glucose levels regularly." "If I become sick I will monitor my blood glucose more frequently and drink lots of fluids." "This condition happens suddenly without any warning signs." "It is important I take my medication as prescribed."

"This condition happens suddenly without any warning signs." HHNS presents GRADUALLY and the patient will experience early signs such as polyuria, polydipsia, and EXTREME hyperglycemia. DKA happens suddenly.

A patient's blood pressure is 80/42 and ICP 22. What is the patient's cerebral perfusion pressure and how do you interpret this finding? A. 33 mmHg, low B. 30 mmHg, normal C. 48 mmHg, low D. 64 mmHg, normal

33 mmHg, low. The MAP is 55. When you calculate the equation: CPP=55-22, you get 33 mmHg as the CPP. Remember a normal CPP is 60-100 mmHg.

What is the GCS for a 29-year-old woman s/p skiing accident into a tree who is intubated; eyes closed even to pain, decorticate posturing only?

5T eyes = 1, intubated = 1T, motor = 3

A patient has symptomatic adrenal insufficiency. What symptoms does the nurse most expect to find? A) Weakness and fatigue B) Constipation and increased appetite C) Bradycardia and bradypnea D) Weight gain and hypertension

A) Weakness and fatigue

You're maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg

A. 5 to 15 mmHg Normal ICP should be 5 to 15 mmHg.

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Examine skin for irritation or pressure. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D. Administer antihypertensive medication.

A. Examine the client's skin for areas of irritation, pressure, or broken skin to alleviate a triggering stimulus. However, another action is the priority. B. Sit the client upright in bed: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure caused by autonomic dysreflexia. The first action to take is to elevate the head of the bed until the client is in an upright position, which should lower the blood pressure secondary to postural hypotension. C. Check the client's catheter for blockage. However, another action is the priority. D. Administer an antihypertensive medication if indicated. However, another action is the priority.

A patient has an infection and reports not checking their blood glucose or regularly taking Metformin. What condition is this patient MOST at risk for? A. HHNS B. DKA C. Metabolic alkalosis D. Metabolic acidosis

A. HHNS

Select all that apply: Which of the following are signs and symptoms of Grave's Disease: A. Heat Intolerance B. Weight gain C. Bradycardia D. Goiter E. Pretibial Myxedema F. Cold intolerance G. Ophthalmopathy changes H. Fast Heart Rate

A. Heat Intolerance D. Goiter E. Pretibial Myxedema G. Ophthalmopathy changes H. Fast Heart Rate The only options that are NOT signs and symptoms of Grave's disease are: weight gain, bradycardia, and cold intolerance....these are S & S of HYPOthyroidism.

Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications

A. Lumbar puncture LPs are avoided in patients with ICP because they can lead to possible brain herniation. BUT ARE NECESSARY WHEN ASSESSING IICP FROM MENENGITIS

A patient who is in her first trimester of pregnancy is diagnosed with hyperthyroidism. Which medication do you suspect the patient will be started on? A. Propylthiouracil (PTU) B. Radioactive Iodine C. Tapazole D. Synthroid

A. Propylthiouracil (PTU) Propylthiouracil (PTU) is the only anti-thyroid medication that can be used during the 1st trimester of pregnancy.

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order with the nurse question? 1. A subcutaneous anti coagulant. 2. An intravenous osmotic diuretics. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

An intravenous osmotic diuretics. An Osmotic diuretic is ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.

A patient with a spinal cord injury and who smokes is at risk for developing deep vein thrombosis (DVT). The nurse provides the patient with antiembolism stockings and encourages her to stop smoking, as it contributes to vasoconstriction in the periphery and thus to DVT. What other measure would be appropriate to help prevent DVT in this patient? A) Administration of atropine sulfate B) Administration of heparin C) Administration of reserpine D) Administration of methyldopa

B) Administration of heparin

A teenaged boy jumped from a two-story building and landed on his feet, injuring his spine, and is now in the ICU. The nurse recognizes his injury as which of the following? A) Rotational injury B) Axial loading C) Hyperflexion D) Hyperextension

B) Axial loading

A patient involved in a motor vehicle accident has a high risk of spinal cord injury. At the scene, what is the priority patient assessment? A) Level of consciousness B) Respiratory rate C) Independent mobility D) Peripheral sensation

B) Respiratory rate

A patient has been diagnosed with partial seizures. What behavior during this patients seizures that would not occur during a generalized seizure does the nurse expect? A) Aura prior to seizure B) Twitching confined to one arm C) Absence of purposeful movement D) Postictal period or state

B) Twitching confined to one arm

During a craniotomy, the patient experienced peripheral damage to cranial nerve VII, resulting in diminished movement of the left side of the face. What nursing action demonstrates best understanding of the effect of this lesion on the patient? A) Referral for speech therapy and swallowing assessment B) Use of ocular moisturizers C) Teaching about falling and syncope risks D)Referral for evaluation for a hearing aid

B) Use of ocular moisturizers

The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby? A. Narcan B. Flumazenil C. Calcium Chloride D. Idarucizumab

B. Flumazenil Flumazenil is the reversal agent for Lorazepam, which is a benzodiazepine.

The nurse notes that a patient with a systemic illness is not demonstrating signs of neurologic involvement. Which physiologic mechanism should the nurse recall that protects the brain from harmful substances? Blood-brain barrier Structure of neurons Large oxygen demand Circulation of cerebrospinal fluid

Blood-brain barrier Rationale: The blood-brain barrier controls the environment within by allowing oxygen, carbon dioxide, lipids, glucose, and water into the capillaries but preventing entry of urea, creatinine, toxins, proteins, and antibiotics. The structure of neurons and cerebrospinal fluid circulation do not protect the brain from harmful substances. The brain has a large oxygen demand to prevent cerebral cell damage

Cushing's triad of symptoms is a protective reflex to increased intracranial pressure (ICP). Symptoms include a widening pulse pressure, a change in respiratory pattern and: Bradycardia Hypotension Paralysis Loss of consciousness

Bradycardia Cushing's triad of symptoms is a protective reflex to increased intracranial pressure (ICP) representing decompensation. Symptoms include a widening pulse pressure, a change in respiratory pattern and bradycardia.

The nurse is assessing a patients level of arousal. Since the patient is unresponsive to verbal and touch stimulation, the nurse decides to try a central pain stimulus. What technique would the nurse be least likely to use? A) Squeeze the trapezius muscle. B) Apply pressure over the supraorbital notch. C) Apply pressure to closed eyelids. D) Perform a sternal rub.

C) Apply pressure to closed eyelids.

A patient was struck in the jaw and had hyperextension of the cervical spine. If the patient has central cord syndrome, what would the nurse most expect? A) Full loss of motor function below the lesion B) Ipsilateral increased cutaneous pain at the lesion C) Arm paralysis with intact motor function in the legs D) Full motor paralysis and loss of touch sensation below the lesion

C) Arm paralysis with intact motor function in the legs

The patient has a depressed skull fracture resulting in a tear of the dura mater. What nursing intervention is most directed at preventing a significant complication of this particular injury? A) Elevating the head of the bed to 15 degrees B) Giving supplemental oxygen by mask C) Ensuring compliance with hand hygiene protocols D) Obtaining consent for surgical repair of fracture

C) Ensuring compliance with hand hygiene protocols

A patient with a mild spinal cord injury becomes light-headed every time she attempts to rise from her bed. At rest, her heart rate and blood pressure are normal. All of her motor, sensory, reflex, and autonomic functions are intact. The nurse recognizes which condition in this patient? A) Spinal shock B) Neurogenic shock C) Orthostatic hypotension D) Central cord syndrome

C) Orthostatic hypotension

A patient with epilepsy experiences a tonic-clonic seizure while in the ICU. What is the most appropriate nursing intervention? A) Leave the patient and find a physician immediately. B) Restrain the patient by tying his wrists to the sides of the bed. C) Turn the patient to his side. D) Administer warfarin.

C) Turn the patient to his side.

How many lumbar vertebrae are there? A. 12 B. 7 C. 5 D. 8

C. 5

How many cervical vertebrae are there? A. 12 B. 5 C. 8 D. 26

C. 8

A patient taking the medication Precose asks when it is the best time to take this medication. Your response is: A. 1 hour prior to eating B. 1 hour after eating C. With the first bite of food D. At bedtime

C. With the first bite of food Precose is an alpha-glucoside inhibitor that works by lowering the blood sugar by slowly breaking down starchy foods in the GI system which helps slowly rise the blood sugar. Therefore, it should be taken with the first bite of food.

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

C. cause vasodilation and increase the ICP An elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie hypothesis.

What is the most common type of seizure in an older adult?

Complex Partial Seizure

The nurse is assessing a patient's cranial nerve function. What equipment should the nurse use to assess function of cranial nerve V, the trigeminal nerve? Cotton ball and safety pin Measuring tape and pencil Scents such as coffee and vanilla Stethoscope with bell and diaphragm

Cotton ball and safety pin Rationale: A cotton ball and a safety pin would be used to assess sensations of light, dull, and sharp on the face. If the safety pin is used to assess sharp touch, the pin is to be discarded as a sharp after use. A measuring tape and pencil might be used to assess cranial diameter. Various scents would be used to assess CN I olfactory nerve function. A stethoscope is not used when assessing the neurologic system.

The nurse is preparing a teaching session on the neurologic system for a group of nursing students. What should the nurse include about the purpose and function of cerebrospinal fluid? (Select all that apply.) Cushions the brain. Helps nourish the brain. Prevents glucose from entering brain cells. Protects the brain and spinal cord from trauma. Removes waste products of cellular metabolism.

Cushions the brain. Helps nourish the brain. Protects the brain and spinal cord from trauma. Removes waste products of cellular metabolism. Rationale: Cerebrospinal fluid (CSF) cushions the brain tissue and spinal cord, protects them from trauma, provides nourishment to the brain, and removes waste products. Glucose is needed in brain cells for normal cell and brain functioning

When describing a patients responsiveness, the nurse uses the term obtunded. What is the most accurate meaning of this term? A) Unable to arouse with any stimulus B) Sedated with intravenous medications C) Having inborn mental retardation D) Arousable but drowsy and slow to respond

D) Arousable but drowsy and slow to respond

A patient with a spinal cord injury has been stabilized in the ICU and now must undergo diagnostic testing. Which test would be most appropriate for detecting a fracture of the vertebra? A) Magnetic resonance imaging (MRI) B) Blood urea nitrogen (BUN) C) Glasgow coma scale (GCS) D) Computed tomography (CT)

D) Computed tomography (CT)

A patient begins to demonstrate loss of consciousness as a result of intracranial pressure. He also demonstrates bradycardia and decreased irregular respirations. Which of the following best describes the identified manifestations? A) Rhinorrhea B) Meningeal irritation C) Cheyne-Stokes respirations D) Cushings triad

D) Cushings triad

A patient presents to the ICU with a spinal cord injury at C3 and the following: loss of position sense, light touch, and vibratory sense below the level of the injury. However, the patient has retained all motor function and pain and temperature sensation. The nurse suspects that the injury has occurred on what portion of the spinal cord? A) Central B) Lateral C) Anterior D) Posterior

D) Posterior

A patient is admitted to the emergency department after a near-drowning accident. The patient dove head-first into shallow water and has a high blood-alcohol level. Cardiopulmonary resuscitation was used at the scene. The patient is awake and alert. Considering the mechanism of injury, what is the highest nursing priority? A) Check vital signs often. B) Obtain an order for radiography studies. C) Monitor pulse oximetry closely. D) Provide cervical spine stability.

D) Provide cervical spine stability.

A patient with a neurologic deficit following traumatic brain injury is making very slow progress toward normal. The family expresses distress and worry about financial and other matters to the nurse. What is the nurses best response? A) Referral for nursing home placement B) Questions about insurance status C) Referral to psychiatry for evaluation D) Referral to multidisciplinary rehabilitation team

D) Referral to multidisciplinary rehabilitation team

The nurse is assessing a patient with a spinal cord injury in the ICU. The patient is completely paralyzed from the waist down but has sensation in his shoulders, chest, arms, and hands. He has no control of his bowel or bladder. Which of the following are possible sites for this patients injury, given his loss of function? Select all that apply. A) C4 B) C7 C) T3 D) T7 E) T12 F) L4

D) T7 E) T12

A patient with seizure disorder is being treated with oral phenytoin (Dilantin). To prevent undesirable side effects of this medication, what is a nursing priority? A) Monitor all seizure activity. B) Use seizure precautions. C) Give medication with milk. D) Teach good oral care.

D) Teach good oral care.

Which statement is true? A. The sacrum consists of 5 fused vertebrae. B. The coccyx consists of 3-5 fused vertebrae. C. There are five main regions in the vertebral column D. All of the above

D. All of the above

A patient has a blood glucose of 400. Which of the following medications could be the cause of this? A. Glyburide B. Atenolol C. Bactrim D. Prednisone

D. Prednisone

The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician? A. The patient's blood pressure is 170/80. B. The patient reports a throbbing headache. C. The patient's lower extremities are pale and cool. D. The patient states they took Sildenafil 12 hours ago.

D. The patient states they took Sildenafil 12 hours ago. A patient should not receive a dose of Nitropaste if they have taken a phosphodiesterase inhibitor within the past 24 hours (Sildenafil or Tadalafil). This will cause major vasodilation and severe hypotension that will not respond to medication. Another medication should be used. All the other findings are expected with autonomic dysreflexia.

A patient is found to have a blood glucose of 375 mg/dL, positive ketones in the urine, and blood pH of 7.25. Which condition is this?* Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) Diabetic ketoacidosis

Diabetic ketoacidosis

The nurse is completing discharge instructions for a client with application of a halo device for spinal cord injury. Which statement indicates more teaching is needed? I will be careful because the halo device can alter my balance I will keep the skin under the vest clean and dry I will only drive during daylight hours I will have someone assess my pin sites daily for redness

I will only drive during daylight hours Clients with halo devices should assess pin sites, keep skin clean and dry and be careful as it can alter balance and fatigue the client. Driving is prohibited a the client cannot turn their head or move independently.

Through genetic testing a patient learns of having markers that indicate immune destruction of the beta cells. Which health problem is this patient prone to developing? Type 2 diabetes mellitus Maturity-onset diabetes mellitus Idiopathic type 1 diabetes mellitus Immune-mediated type 1 diabetes mellitus

Immune-mediated type 1 diabetes mellitus Rationale: Immune-mediated type 1 diabetes mellitus leads to the destruction of beta cells and absolute insulin deficiency. The rate of beta-cell destruction is variable, usually more rapid in infants and children and slower in adults. Idiopathic type 1 diabetes mellitus has no known cause. It is believed to be an inherited disorder and the needs for insulin may be intermittent. Type 2 diabetes mellitus is a disorder that ranges from insulin resistance to insulin deficiency. There is no immune destruction of beta cells. Maturity-onset diabetes mellitus is caused by a genetic defect within the beta cell that causes hyperglycemia to occur before the age of 25.

What vertebrae injured cause some loss function in hips and legs, no control bowel and bladder, can use wheelchair or braces to walk?

L1-L5

Following a motorcycle crash, a patient is diagnosed with damage to the posterior spinal roots. What should the nurse expect to assess in this patient? Flaccid paralysis of the legs Loss of sensation to dull and sharp Decreased sense of smell and taste Changes in peripheral vision in both eyes

Loss of sensation to dull and sharp Rationale: The posterior spinal roots contain cells that discriminate fine touch sensations such as dull and sharp; therefore, damage to these roots would mean the patient would be unable to detect dull or sharp sensations. Flaccidity is seen with diseases or trauma of the lower motor neurons and early stroke. Anosmia or an inability to smell may be seen with lesions of the frontal lobe and may also occur with impaired blood flow to the middle cerebral artery. Loss of ability to taste may occur with brain tumors or with nerve impairment. Impaired vision may be seen with strokes and brain tumors

Which is a priority for the diabetic patient who is taking insulin and has nausea and vomiting from a virus? Monitor blood glucose levels Maintaining an exercise routine Relieving pain Proper rest and sleep

Monitor blood glucose levels Rationale: Illness can cause clients to be unable to maintain nutrition and fluid intake. Clients need to monitor blood sugar levels to ensure adequate control during illness.

A nurse is planning a seminar for city public health workers on ways to reduce the onset of central nervous system infections in the community. On which topic should the nurse focus in this seminar? Garbage pickup Sanitation services Mosquito spraying Washing fruits and vegetables

Mosquito spraying Rationale: To reduce the onset of CNS infections in a community, the nurse should focus on the control of mosquitoes with repellants, insecticides, and protective clothing. Community programs such as spraying to destroy the insect larvae and eliminate breeding places, such as pools of stagnant water, should also be provided. Garbage pickup, sanitation services, and the washing of fruits and vegetables will not reduce the infestation of mosquitoes

Jane Thomas is a 56-year-old female. She was admitted 4 days ago and underwent a lumbar laminectomy. She was able to ambulate with assistance on day 2 after surgery and now reports no dizziness on ambulation. Her leg strength has progressively increased since surgery. She has equal sensation and is able to wriggle her toes on both feet. Pain is controlled at the patient's desired level of 2 to 3 on a scale of 1 to 10 with oral medications. Before she is discharged, what instruction should be given to Ms. Thomas regarding lifting and moving objects?

Ms. Thomas should be taught not to lift or move anything over 10 pounds until her surgeon approves. Once healing is complete, she must lift by using her legs, not her back. Rationale: Lifting can traumatize the incision and prevent adequate healing. Using the back to lift heavy objects can cause further injury to lumbar discs.

In spinal cord injuries, what vertebrae are injured for a patient to have control of urinary continence?

S2-S4

The nurse is caring for a patient with altered level of consciousness. On which laboratory value should the nurse focus as the most accurate indicator of hydration status in the patient? CBC Urinalysis Blood culture Serum osmolality

Serum osmolality Rationale: Serum osmolality is an indicator of hydration status. The test measures the number of dissolved particles such as electrolytes, urea, and glucose in the serum. The complete blood count and urinalysis will not provide information about the patient's hydration status. Blood cultures are used to determine the presence of a bacterial infection in the blood

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 2x2 Gauze under the nose to collect drainage.

Test the drainage for presence of glucose. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid and the HCP should be notified immediately.

The nurse is caring for the following clients. Which client what 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 2 hours. 2. The 36 year old female client admitted with complaints of left sided weakness who is scheduled for an 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 CVA who has expressive aphasia.

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. The Glasgow Coma Scale is used to determine a client's response to stimuli such as eye opening response, best verbal response, and best motor response secondary to a neurological problem scores range from 3 which is a deep coma to 15 which is intact neurological function. A client with a score of 6 should be assessed first.

A patient undergoing treatment for Hyperglycemic Hyperosmolar Nonketotic Syndrome has a blood glucose of 799. The doctor has ordered intravenous fluids and intravenous Regular insulin therapy. Which of the following findings causes concern before starting insulin therapy? Regular insulin cannot be given intravenously; therefore, the nurse needs to clarify the doctor's order. The patient's potassium level is 3.1. The patient is complaining of severe thirst and has dry mucous membranes. The patient is confused and drowsy.

The patient's potassium level is 3.1. Prior to insulin administration for HHNS the potassium level should be >3.3 because insulin causes potassium to enter back to the cell....which will cause further hypokalemia.

A patient with a thoracic spinal cord injury is experiencing spinal shock. How should the nurse explain this pathophysiologic process to the patient? There is damage to the lower motor neurons. There is an exaggerated sympathetic response. There is a loss of control of cardiovascular mechanisms. There is a temporary loss of reflex function below the level of injury.

There is a temporary loss of reflex function below the level of injury. Rationale: Spinal shock is the response of the cord itself to injury. It involves temporary loss of reflex function below the level of injury at the cervical and upper thoracic spinal cord. Spinal shock is not damage to the lower motor neurons. Spinal shock interrupts sympathetic nerve functioning. Spinal shock leads to a loss of sympathetic input to the blood vessels of the peripheral system and the heart, leading to unopposed vagal tone. Control of cardiovascular mechanisms is not lost but altered

The nurse is caring for a patient with increased intracranial pressure. Why should the nurse expect osmotic diuretics to be prescribed for this patient? To treat hyperthermia. To prevent the onset of seizures. To reduce the risk for gastrointestinal hemorrhage. To draw edematous fluid into the vascular system.

To draw edematous fluid into the vascular system. Rationale: Osmotic diuretics are hyperosmotic agents that draw fluid out of brain cells by increasing the osmolality of the blood. These medications excrete water and leave behind solutes. Osmotic diuretics are not used to treat hyperthermia, prevent seizures, or prevent gastrointestinal hemorrhages

True or False: When priming the tubing for an Insulin infusion it is best practice to waste 50cc to 100cc of insulin prior to starting the infusion because insulin absorbs into the plastic lining of the tubing.

True

A patient is admitted with a subacute subdural hematoma. The nurse realizes this patient will most likely be treated with: a.) Emergency craniotomy. b.) Elective draining of the hematoma. c.) Burr holes to remove the hematoma. d.) Removal of the affected cranial lobe.

b.) Elective draining of the hematoma.

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? a.) Absence of pain sensation in chest b.) Spasticity c.) Spontaneous respirations d.) Urinary continence

b.) Spasticity Rationale: Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.

What type of brain injury occurs due to swelling or impaired blood flow to the area of the injury (i.e. Increased Intracranial pressure, infection, ischemia, hypoxia) a. Diffuse Axonal Injury b. Focal Injury c. Secondary Injury d. Primary Injury

c. Secondary Injury

During an assessment of a patient's motor status with the Glasgow Coma scale, the patient assumes a posture of abnormal flexion. The nurse would document this finding as: a.) 5 b.) 4 c.) 3 d.) 2

c.) 3

A client with a C4 spinal injury would most likely have which of the following symptoms? a.) Aphasia b.) Hemiparesis c.) Paraplegia d.) Tetraplegia

d.) Tetraplegia Rationale: Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.

A client has suffered a spinal cord injury after a diving accident. When first brought to the emergency room, the patient is suffering from spinal shock. Which symptom is most consistent with this condition? cool clammy skin back pain flaccid paralysis blurred vision

flaccid paralysis Rationale: Spinal shock results from initial swelling form a spinal cord injury and causes temporary loss of function and parasympathic dysfunction. Sings include flaccid paralysis, bradycardia, hypotension, paralytic ileus and loss if DTRs.

A patient's blood pressure is 110/74 and ICP is 8. What is the patient's cerebral perfusion pressure? A. 94 mmHg B. 56 mmHg C. 98 mmHg D. 78 mmHg

78 mmHg. The MAP is 86. When you calculate the equation: CPP= 86-8, you get 78 mmHg as the CPP.

A patient's blood pressure is 152/96 and ICP is 20. What is the patient's cerebral perfusion pressure? A. 115 mmHg B. 20 mmHg C. 95 mmHg D. 56 mmHg

95 mmHg. The MAP is 115. When you calculate the equation: CPP= 115-20, you get 95 mmHg as the CPP.

Phrenic nerve intact, but not intercostal muscles for what injured vertebrae?

C5-C8

After failing to effectively clear a patients airway by having him cough, the nurse is now suctioning his airway. What complication related to suctioning should the nurse be aware of? A) Bradycardia B) Tachycardia C) Hyperglycemia D) Hypertension

A) Bradycardia

Which patient is MOST likely to develop Diabetic Ketoacidosis? A 25 year old female newly diagnosed with Cushing's Disease taking glucocorticoids. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin. A 35 year old female newly diagnosed with Type 2 diabetes. None of the options are correct.

A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin.

A patient's blood pressure 92/56 and ICP 6. What is the patient's cerebral perfusion pressure and how do you interpret this finding? A. 82 mmHg, normal B. 56 mmHg, low C. 62 mmHg, normal D. 108 mmHg, high

62 mmHg, normal. The MAP is 68. When you calculate the equation: CPP=68-6, you get 62 mmHg as the CPP. Remember a normal CPP is 60-100 mmHg.

A patient's mean arterial pressure is 82 and ICP is 15. What is the patient's cerebral perfusion pressure? A. 67 mmHg B. 100 mmHg C. 52 mmHg D. 30 mmHg

67 mmHg. The MAP is 82. When you calculate the equation: CPP= 82-15, you get 67 mmHg as the CPP.

How many thoracic vertebrae are there? A. 12 B. 7 C. 5 D. 26

A. 12

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Avoid overwhelming fatigue. B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. D. Perform aerobic exercise. E. Limit episodes of hypoventilation. F. Use of aerosol hairspray is recommended.

A. Avoid overwhelming fatigue: The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity. B. Remove caffeinated products from the diet: The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity. C. Limit looking at flashing lights: The nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuron activity. D. The nurse should instruct the client to avoid vigorous physical activity, which can help to avoid triggering a seizure. E. The nurse should instruct the client to limit excess hyperventilation, which can trigger a seizure by stimulating abnormal electrical neuron activity. F. The nurse should instruct the client to avoid using aerosol hairspray, which can trigger a seizure by stimulating abnormal electrical neuron activity.

Signs and Symptoms of myxedema coma include all of the following EXCEPT? Select all that apply: A. Fever B. Bradycardia C. Sodium level less than 135 D. Blood glucose level greater than 350 E. Hypothermia

A. Fever D. Blood glucose level greater than 350

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? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. Headache: Headache is a finding associated with increased ICP. B. Dilated pupils: Dilated pupils is a finding associated with increased ICP. C. Bradycardia, not tachycardia, is a finding associated with increased ICP. D. Decorticate posturing: Decorticate or decerebrate posturing is a finding associated with increased ICP. E. Hypertension, not hypotension, is a finding associated with increased ICP.

Which of the following signs and symptoms causes concern and requires nursing intervention for a patient who recently had a thyroidectomy? A. Heart rate of 120, blood pressure 220/102, temperature 103.2 'F B. Heart rate of 35, blood pressure 60/43, temperature 95.3 'F C. Soft hair, irritable, diarrhea D. Constipation, drowsiness, goiter

A. Heart rate of 120, blood pressure 220/102, temperature 103.2 'F A patient is at risk for experiencing thyroid storm after a thyroidectomy because of manipulation of the thryroid gland that could cause excessive T3 and T4 to enter into the bloodstream during removal of the gland. Therefore, heart rate of 120, blood pressure 220/102, temperature 103.2 'F are classic signs of thyroid storm and this requires nursing intervention.

A nurse in a provider's office is reviewing the health record of a client who is being evaluated for Graves' disease. The nurse should identify that which of the following laboratory results is an expected finding? A. Decreased thyrotropin receptor antibodies B. Decreased thyroid-stimulating hormone (TSH) C. Decreased free thyroxine index D. Decreased triiodothyronine

A. In the presence of Graves' disease, elevated thyrotropin receptor antibodies is an expected finding. B. Decreased thyroid-stimulating hormone (TSH): In the presence of Graves' disease, low TSH is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated. C. In the presence of Graves' disease, elevated free thyroxine index is an expected finding. D. In the presence of Graves' disease, elevated triiodothyronine is an expected finding.

A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves' disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Monitor CBC. B. Monitor triiodothyronine (T3). C. Instruct the client to increase consumption of shellfish. D. Advise the client to take the medication at the same time every day. E. Inform the client that an adverse effect of this medication is iodine toxicity.

A. Monitor CBC: Methimazole can cause a number of hematologic effects, including leukopenia and thrombocytopenia. Monitor CBC. B. Monitor triiodothyronine (T3): Methimazole reduces thyroid hormone production. Monitor T3. C. Methimazole reduces thyroid hormone production by blocking iodine. Instruct the client to limit iodine containing foods (shellfish). D. Advise the client to take the medication at the same time every day: Methimazole should be taken at the same time every day to maintain blood levels. E. Iodine toxicity is an adverse effect of potassium iodide solution.

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. Prevention of further damage to the spinal cord: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention to take is to prevent further damage to the spinal cord by minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord. B. Implement ROM exercise to prevent contractures. However, another action is the priority. C. Implement a turning schedule to prevent skin breakdown. However, another action is the priority. D. Slowly move the client to an upright position to prevent postural hypotension. However, another action is the priority.

A patient newly diagnosed with diabetes is about to be discharged home. You are watching the patient administer insulin. Which of the following actions causes you to re-educate them? A. They massaged the site after administering the insulin. B. They injected into the fat of their thighs. C. They used an opposite side for injection compared to the last insulin injection. D. They engaged the safety after administering the medication.

A. They massaged the site after administering the insulin.

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply.) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis

A. Weight loss occurs when the cells are unable to use glucose because of insulin deficiency and places the body in a catabolic state, and fluid loss from dehydration decreases body weight. B. Fruity odor of breath: Fruity odor of breath is a manifestation of elevated ketone levels that lead to metabolic acidosis. C. Abdominal pain: Abdominal pain is a GI manifestation of increased ketones and acidosis. D. Kussmaul respirations: Kussmaul respirations are an attempt to excrete carbon dioxide and acid when in metabolic acidosis. E. Metabolic acidosis: Metabolic acidosis is caused by glucose, protein, and fat breakdown, which produces ketones.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return to normal.

A. Urine output increases. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. The mannitol causes the cells in the brain to dehydrate mildly. The water inside the brain cells (intracellular water) leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream. Once in the bloodstream, the extra water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys filter the mannitol into the urine. The mannitol again draws the water with it, and diuresis (increased urination) ensues. Option B: Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma. Visual changes can range from blurred vision, double vision from cranial nerve defects, photophobia to optic disc edema, and eventually optic atrophy. Option C: There is no indication that mannitol is being given for renal dysfunction or blood pressure maintenance. Intradialytic hypotension and dialysis disequilibrium symptoms are common in hemodialysis patients. This is due to a drop in intradialytic osmolality. Mannitol can be used to prevent intradialytic hypotension by raising serum osmolality. Option D: No information is given about abnormal BUN and creatinine levels. Much like mannitol given for oliguria of acute renal failure, mannitol can be given to increase the excretion of toxic materials, substances, and drugs. The kidneys excrete mannitol. The mannitol is poorly reabsorbed once excreted and thus draws extra water with it into the renal collecting ducts. The extra water in the renal collecting ducts can help increase the excretion of water-soluble toxic materials, substances, and drugs.

Which of the following medication orders should a nurse question if ordered on a patient with thyroid storm? A. Propylthiouracil "PTU" for a 25 year old who is 8 weeks pregnant B. Aspirin as needed for a fever greater than 102.2 'F C. Inderal for a patient who reports having insomnia D. Tapazole for a 30 year old having complaints of a headache

B. Aspirin as needed for a fever greater than 102.2 'F A patient who has hyperthyroidism or thyroid storm should NEVER take salicylate (ex: aspirin) because it can increase thyroid hormones. All the other options are correct or insignificant for why the patient is taking the medication.

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst

B. Crackles throughout lung fields Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.

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

B. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect. C5 to C7 are responsible for deep tendon reflexes of the biceps, brachioradialis, and triceps respectively. C5 controls shoulder abduction with the aid of C4 and elbow flexion with the aid of C6. C6 to C7 are responsible for elbow extension, wrist extension, and flexion. Option A: Conus medullaris Syndrome is caused by injury to the terminal aspect of the spinal cord, just proximal to the cauda equina. It characteristically presents with loss of sacral nerve root functions. Loss of Achilles tendon reflexes, bowel and bladder dysfunction, and sexual dysfunction may be observable. Option C: C3 to C4 contributes to breathing by controlling the muscles of the diaphragm. Patients with an injury in this area of the cervical spine can complain of difficulty breathing. If C3 or C4 are involved, abnormal breathing or respiratory failure can occur. Option D: Neurogenic Shock results from high cervical injuries affecting the cervical ganglia, which leads to a loss of sympathetic tone. Loss of sympathetic tone results in a shock state characterized by hypotension and bradycardia.

1. Fill in the blank regarding the negative feedback loop for thyroid hormone production: The ______________ produces TRH (Thyrotropin-Releasing Hormone) which causes the anterior pituitary gland to produce _______________ which in turn causes the thyroid gland to release _______ and _______. A. Thalamus, CRH (Corticotropin-releasing hormone) TSH (thyroid-stimulating hormone) and T4 B. Hypothalamus, TSH (thyroid-stimulating hormone), T3 and T4 C. Posterior pituitary gland, TSH (thyroid-stimulating hormone), T3 and T4 D. Hypothalamus, CRH (Corticotropin-releasing hormone), TSH (thyroid-stimulating hormone), T3 and TSH

B. Hypothalamus, TSH (thyroid-stimulating hormone), T3 and T4

External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle

B. Lateral Ventricle External ventricular drains (also called ventriculostomy) are inserted in the lateral ventricle.

Which of the following are not a treatment for Thyroid Storm? A. Propylthiouracil (PTU) B. Synthroid C. Inderal D. Glucocorticoids

B. Synthroid (levothyroxine) Synthroid is a medication treatment for HYPOthyroidism. All the other options are for HYPERthyroidism.

A patient is post-opt from a thyroidectomy for treatment of Grave's Disease. When you walk into the patient's room to perform an assessment, which of the following findings causes the MOST concern and needs nursing intervention? A. The patient complains of a pain rating of 4 on 1-10 at the surgical site. B. The patient is positioned in supine position. C. The patient's Foley catheter is draining 50 cc of urine per hour. D. The patient is splinting the neck while coughing and deep breathing.

B. The patient is positioned in supine position. The MOST concerning option is that the patient is in the supine position. The patient should be in SEMI-FOWLER'S position after a thyroidectomy to prevent excessive swelling/bleeding and pressure on the site.

A patient with diabetes is experiencing a blood glucose of 275 when waking. What is a typical treatment for this phenomenon? A. None, this is a normal blood glucose reading. B. The patient may need a night time dose of an intermediate-acting insulin to counteract the morning hyperglycemia. C. A bedtime snack may prevent this phenomenon. D. This is known as the Somogyi effect and requires decreasing the bedtime dose of insulin.

B. The patient may need a night time dose of an intermediate-acting insulin to counteract the morning hyperglycemia. This is known as the DAWN PHENOMENON and is best treated with a night time dose of an intermediate-acting insulin to counteract the morning hyperglycemia.

Laboratory tests are being prescribed for a patient with altered level of consciousness. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.) Blood glucose Urine for WBCs Serum electrolytes Spinal fluid osmolarity Blood and urine toxicology

Blood glucose Serum electrolytes Blood and urine toxicology Rationale: A patient with an altered LOC would probably have blood glucose level checked for hypoglycemia, electrolytes checked for metabolic disturbances, and blood and urine toxicology studies to test for drug or alcohol toxicity. Urine white blood cell levels would not be indicated for the patient's health problem. Spinal fluid osmolarity would be done after a lumbar puncture, which is a diagnostic test.

Which of the following is NOT a typical finding in HHNS? Blood pH <7.35 Dehydration Mental status changes Osmotic diuresis

Blood pH <7.35

A patient with a cervical spine fracture has been fitted with a halo vest and is to ambulate for the first time today. What is the priority nursing action? A) Put rubber corks on the ends of the pins. B) Pad the edges of the vest to prevent chafing. C) Have the patient sit on the side of the bed for several minutes. D) Teach about loss of peripheral vision.

C) Have the patient sit on the side of the bed for several minutes.

Which of the following is NOT a medical treatment for DKA and HHNS? A. IV regular insulin B. Isotonic fluids C. Bicarbonate D. IV potassium Solution

C. Bicarbonate

Neurons in the brain are tasked with handling and transmitting information. There are different types of neurons, such as excitatory and inhibitory. Excitatory neurons release the neurotransmitter _____________, while inhibitory neurons release the neurotransmitter ________________. A. GABA, glutamate B. Norepinephrine, GABA C. Glutamate, GABA D. Dopamine, glutamate

C. Glutamate, GABA Excitatory neurons release glutamate and inhibitory neurons release GABA.

A patient is admitted with complaints of palpations, excessive sweating, and unable to tolerate heat. In addition, the patient voices concern about how her appearance has changed over the past year. The patient presents with protruding eyeballs and pretibial myxedema on the legs and feet. Which of the following is the likely cause of the patient's signs and symptoms? A. Thyroiditis B. Deficiency of iodine consumption C. Grave's Disease D. Hypothyroidism

C. Grave's Disease

Which patient population is most at risk for DKA? A. Middle-aged adults who are obese B. Older-adults with Type 2 diabetes C. Newly diagnosed diabetes D. None of the options

C. Newly diagnosed diabetes

Which of the following is not a sign or symptom of Diabetic Ketoacidosis? A. Positive Ketones in the urine B. Polydipsia C. Oliguria D. Abdominal Pain

C. Oliguria

The ______ ______secretes ACTH which causes the ______ ______ to produce cortisol. A. Hypothalamus, adrenal medulla B. Thalamus, pituitary gland C. Pituitary gland, adrenal cortex D. Adrenal cortex, pituitary gland

C. Pituitary gland, adrenal cortex

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

C. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation. Option A: Autonomic dysreflexia occurs after neurogenic shock abates. Neurogenic shock is defined as the injury to the spinal cord with associated autonomic dysregulation. This dysregulation is due to a loss of sympathetic tone and an unopposed parasympathetic response. Neurogenic shock is most commonly a consequence of traumatic spinal cord injuries. Option B: Hypervolemia is indicated by rapid and bounding pulse and edema. The joint committee of the American Spinal Injury Association and the International Spinal Cord Society proposed the definition of a neurogenic shock to be general autonomic nervous system dysfunction that also includes symptoms such as orthostatic hypotension, autonomic dysreflexia, temperature dysregulation. Option D: Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate. Though neurogenic shock should be considered only after a hemorrhagic shock has been ruled out in a traumatic patient, the presence of vertebral fracture or dislocation raises the concern for a neurogenic shock. Bradyarrhythmia, hypotension, flushed warm skin are the classic signs associated with neurogenic shock.

After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition? A. Skin break down B. Blood glucose C. Possible bladder irritant D. Last bowel movement

C. Possible bladder irritant A bladder issue is usually the most common cause of AD. If this isn't the issue the nurse should assess the bowel and then the skin for break down.

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive

C. Raise the head of the bed The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in high Fowler's position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke. Options A & B: After positioning the client in high Fowler's position, the nurse should remove any noxious stimuli that may trigger autonomic dysreflexia by loosening any tight clothing or objects that might be tight-fitting such as a bracelet, shoes, or stockings and check the bladder if it is too full. Option D: Antihypertensive medication may be prescribed such as nifedipine and nitrates to decrease cerebral hypertension.

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

C. Restlessness Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.

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

C. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Measure serial ABGs and pulse oximetry. Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications. Option A: Identify and monitor precipitating risk factors (bladder and bowel distension or manipulation; bladder spasms, stones, infection; skin/tissue pressure areas, prolonged sitting position; temperature extremes or drafts). Visceral distention is the most common cause of autonomic dysreflexia, which is considered an emergency. Treatment of acute episodes must be carried out immediately (removing stimulus, treating unresolved symptoms), then interventions must be geared toward prevention. Option B: Assess and document sensory function or deficit (by means of touch, pinprick, hot or cold, etc.), progressing from an area of deficit to a neurologically intact area. Changes may not occur during acute phase, but as spinal shock resolves, changes should be documented by dermatome charts or anatomical landmarks ("2 in above nipple line"). Option D: Although the other options would be necessary at a later time, observation for respiratory failure is the priority. Encourage expressions of sadness, grief, guilt, and fear among the patient, SO, and friends. Knowledge that these are appropriate feelings that should be expressed may be very supportive to the patient and SO.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. Restlessness and confusion The earliest symptom of elevated ICP is a change in mental status. Following the neurological exam closely is very important. Usually, there is an altered mental status and development of a fixed and dilated pupil. Patients presenting with findings suggestive of cerebral insult should undergo computed tomography (CT) scan of the brain; this can show the edema, which is visible as areas of low density and loss of gray/white matter differentiation, on an unenhanced image. Option A: High blood pressure causes reflex bradycardia and brain stem compromise affecting respiration. Ultimately the contents of the cranium are displaced downwards due to the high ICP, causing a phenomenon known as herniation which can be potentially fatal. Option D: Cushing triad is a clinical syndrome consisting of hypertension, bradycardia, and irregular respiration and is a sign of impending brain herniation. This occurs when the ICP is too high the elevation of blood pressure is a reflex mechanism to maintain CPP. Option B: The client may void large amounts of very dilute urine if there's damage to the posterior pituitary. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma. Visual changes can range from blurred vision, double vision from cranial nerve defects, photophobia to optic disc edema, and eventually optic atrophy.

Your patient has entered the post ictus stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Immediate return to baseline behavior C. Sleepy, headache, and soreness D. Unconsciousness

C. Sleepy, headache, and soreness Based on the findings during the seizure the patient experienced a tonic-clonic seizure. In the post ictus stage (after the seizure) the patient is expected to be sleepy (very tired), have soreness, and a headache. The nurse should let the patient sleep.

A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A. Focal Impaired Awareness (complex partial) B. Atonic C. Tonic-clonic D. Absence

D. Absence This is an absence seizure and is most common in children. The hallmark of it is staring that appears to be like a daydreaming state. It is very short and the post ictus stage of this type of seizure is immediate.

A patient has a blood glucose of 58 and is sweating, cold, and clammy. The patient is conscious. What is your next nursing intervention? A. Recheck the blood glucose in 5 minutes. B. Give the patient 15 grams of a complex carbohydrate. C. No intervention is needed because this is a normal blood glucose. D. Give the patient 15 grams of a simple carbohydrate.

D. Give the patient 15 grams of a simple carbohydrate. Simple carbohydrates work faster than complex. Example of a simple carbohydrate would be 4 oz of fruit juice or soda, glucose tablet or gel, etc.

A patient has an extremely high T3 and T4 level. Which of the following signs and symptoms DO NOT present with this condition? A. Weight loss B. Intolerance to heat C. Smooth skin D. Hair loss

D. Hair loss

A patient is 6 hours post-opt from a thyroidectomy. The surgical site is clean, dry and intact with no excessive swelling noted. What position is best for this patient to be in? A. Fowler's B. Prone C. Trendelenburg D. Semi-Fowler's

D. Semi-Fowler's

During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.

D. The eyes will be in a fixed mid-line position as the head is moved side to side. This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign.

A patient is demonstrating manifestations of autonomic dysreflexia. What will the nurse most likely assess as the reason for this health problem? Diarrhea Distended bladder Elevated blood pressure Respiratory wheezes and stridor

Distended bladder Rationale: Autonomic dysreflexia is triggered by stimuli that would normally cause abdominal discomfort, by stimulation of pain receptors, and by visceral contractions. The most common cause is from a full bladder resulting from a blocked urinary catheter. Diarrhea and respiratory problems do not cause autonomic dysreflexia. An elevated blood pressure is a manifestation of this disorder

Which of the following statements are INCORRECT about Diabetic Ketoacidosis? Extreme Hyperglycemia that presents with blood glucose >600 mg/dL Ketones are present in the urine Metabolic acidosis is present with Kussmaul breathing Potassium levels should be at least 3.3 or higher during treatment of DKA with insulin therapy

Extreme Hyperglycemia that presents with blood glucose >600 mg/dL Extreme Hyperglycemia that presents with blood glucose >600 mg/dL is present only in Hyperglycemic Hyperosmolar Nonketotic Syndrome.

True or False: Hypertonic fluids, such as 3% saline, are the first line of treatment to correct dehydration in HHNS.

False Isotonic (0.9% NS) solutions are usually the first-line treatment or the physician may order a hypotonic solution such 0.45% NS to replenish the dehydrated cell. ....this depends on the severity of dehydration. A 5% Dextrose 0.45% NS may be added when the glucose has reached 300 mg/dL, but is not first-line treatment. However, 3% Saline is never used.

True or False: The Somogyi effect causes the patient to experience an increase in their blood glucose during the hours of 2-3 am.

False The Somogyi effect causes the patient to experience a DECREASE in their blood glucose during the hours of 2-3 am.

True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

False The statement should say: The sympathetic (NOT parasympathetic) nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

This condition happens gradually and is more likely to affect older adults? HHNS DKA

HHNS

Which of the following statements is INCORRECT about Hyperglycemic Hyperosmolar Nonketotic Syndrome? HHNS occurs mainly in type 2 diabetics. This condition presents without ketones in the urine. Metabolic alkalosis presents in severe HHNS. Intravenous Regular insulin is used to treat hyperglycemia.

Metabolic alkalosis presents in severe HHNS.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started. B. Maintain enteric precautions. C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. D. Maintain neutropenic precautions.

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Antibiotics are given to treat the underlying causes of inflammation and thus prevent the occurrence of seizure activity. Option A: Assess neurologic status to include VS pattern, changes in consciousness, behavior patterns and pupillary/ocular responses appropriate for age (measure head circumference in infant) (specify when). Administer antibiotics as prescribed (specify) as soon as ordered based on analysis of CSF, throat cultures. Option B: Enteric precautions are taken to prevent infections that are transmitted primarily by direct or indirect contact with fecal material. They're indicated for patients with known or suspected infectious diarrhea or gastroenteritis. Clostridium difficile is the most common cause of hospital-acquired infectious diarrhea. Option D: Neutropenic precautions are steps one can take to prevent infections if they have moderate to severe neutropenia. Neutropenia is a condition that causes the client to have low neutrophils in the blood. Neutrophils are a type of white blood cell that helps the body fight infection and bacteria. Ask a healthcare provider for more information on neutropenia.

The nurse is enjoying a day out 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 clients loc. 2. Organize onlookers to remove the client from the lake. 3. Perform a head to toe assessment to determine injuries. 4. Stabilize the clients cervical spine.

Stabilize the clients cervical spine. The nurse should always assume that the client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis. Therefore the nurse should stabilize the cervical spinal cordes best as possible prior to removing the client from the water.

What is the GCS for 20-year-old woman s/p motorcycle collision with open eyes, grunting only, and withdrawals to pain?

10 eyes = 4, motor = 4, verbal = 2

Which of the following patients is MOST LIKELY experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms? A 72 year old with a health history of diabetes who has a blood glucose of 300 mg/dL and is complaining of thirst and frequent urination. A 66 year old with type I diabetes that has ketones present in their urine. A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL. A 6 year old that is presenting with polyuria, polydipsia, abdominal pain, and vomiting.

A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL. Hallmark of HHNS is an EXTREME high blood glucose (>600 mg/dL), is precipitated by infection, and is more common in type 2 diabetics. The 69 year old is a type 2 diabetic due to the clue that the option states the patient has missed doses of Metformin (which is an oral type 2 diabetic medication). DKA presents with elevated blood glucose >300 mg/dL and ketones which HHNS does not.

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 or symptoms would warrant transferring the resident to the emergency department? 1. A 4 centimeters 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's resolved with medication.

A weak pulse, shallow respirations, and cool pale skin. These signs and symptoms indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

A patient with traumatic brain injury is found to have bilateral lesions deep in the cerebral hemispheres. What respiratory pattern should the nurse most expect to find in this patient? A) Alternating hyperpneic and apneic phases (Cheyne-Stokes breathing) B) Sustained, regular, rapid, and deep hyperventilation (neurogenic hyperventilation) C) Long pause at full inspiration or full expiration (apneustic breathing) D) Gasping breaths with irregular pauses (cluster breathing)

A) Alternating hyperpneic and apneic phases (Cheyne-Stokes breathing)

A patient with traumatic brain injury is experiencing cerebral edema, which has led to severely elevated intracranial pressure. He has increased pulse pressure, decreased heart rate, and an irregular respiratory pattern. He has lost consciousness and demonstrates bilateral pupillary dilation. The nurse recognizes that these symptoms point to which condition? A) Central herniation syndrome B) Uncal herniation syndrome C) Cerebrovascular injury D) Diffuse axonal injury

A) Central herniation syndrome

An inexperienced nurse who is new to the ICU is examining the eyes of a comatose patient with traumatic brain injury who is on a ventilator. In doing so, she turns the patients head sharply to one side. After she is finished, she leaves the patients head turned to the side. A more experienced nurse sees this and cautions the new nurse not to turn the patients head so sharply or leave it in that position. What is the best rationale for the more experienced nurses admonition? A) Compression of the jugular vein leading to increased intracranial pressure B) Lack of a patent airway C) Lack of dignity for the patient D) Cramping of neck muscles

A) Compression of the jugular vein leading to increased intracranial pressure

A patient has trouble shrugging his shoulders and turning his head from side to side against resistance. Which nerve should the nurse suspect to be involved? A) Cranial nerve XI B) Cranial nerve XII C) Cranial nerve X D) Cranial nerve IX

A) Cranial nerve XI

During a neurologic examination, the nurse finds bilateral pronator drift and diminished ability to raise legs against resistance. These findings are consistent with what neurologic deficit? A) Damage to motor neuron pathways B) Hyperthyroidism C) Demyelinization of afferent fibers D) Cerebral cortex hypoperfusion

A) Damage to motor neuron pathways

The patient has an acute subdural hematoma from an acute head injury. What is the most typical symptom that the nurse would expect during the first 2 days after the injury? A) Decreasing level of consciousness B) Labile blood pressure C) Cardiac dysrhythmias D) Impingement of cranial nerve 8

A) Decreasing level of consciousness

One of the major goals of therapy for a patient with a head injury is to control rising intracranial pressure (ICP). What assessment data would first cause the nurse to suspect rising ICP? A) Deteriorating level of consciousness B) Brisk pupils with equal reactivity C) Absence of speech secondary to sedative use D) Narrow pulse pressure and hypotension

A) Deteriorating level of consciousness

The nurse is performing a physical examination on a patient with neurologic disease. What finding from the examination is the most indicative of diminished cerebral hemisphere functioning? A) Deteriorating level of consciousness B) Positive Romberg test C) Unequal pupillary response D) Glasgow Coma Scale score of 15

A) Deteriorating level of consciousness

A patient has a C7-C8 spinal cord injury. During recovery, what is the nursing priority of care? A) Encourage the patient to do incentive spirometry exercises. B) Monitor neurologic status every 4 hours. C) Collaborate with physical therapy for exercises. D) Refer to social services for financial assistance.

A) Encourage the patient to do incentive spirometry exercises.

A patient who was in a motor vehicle accident struck her forehead on the windshield of her car after crashing into the back of another car. Given this mechanism of injury, which regions of the brain are most likely to be injured? Select all that apply. A) Frontal lobes B) Parietal lobes C) Occipital lobes D) Temporal lobes E) Diencephalon F) Medulla oblongata

A) Frontal lobes C) Occipital lobes

A patient has experienced a traumatic brain injury. During initial assessment, the nurse determines that the mechanism of injury was acceleration deceleration. What is the best rationale for this nursing assessment? A) Helps to predict nature of internal injuries B) Satisfied the nurses curiosity C) Required on admission form D) May be part of legal evidence

A) Helps to predict nature of internal injuries

Although awake and alert, a patient who has experienced a neurologic insult is having difficulty maintaining a patent airway and requires frequent jaw thrust maneuvers. What neurologic damage is this finding most closely associated with? A) High cervical spinal cord lesion B) Cerebral infarction of the brainstem C) Damage to the eighth cranial nerve D) Damage to the second and third cranial nerves

A) High cervical spinal cord lesion

A patient with serious neurologic trauma is being evaluated for brain death using cerebral blood flow studies. What is the most accurate information the nurse can provide when discussing the test with the family? A) If the test shows no blood flow to the cerebral hemispheres, brain death is definite. B) If the test shows adequate flow to the cerebral hemispheres, the brain is viable. C) The test will give a more accurate measurement of intracranial pressure. D) The test is performed only after all sedative and pain medications are discontinued.

A) If the test shows no blood flow to the cerebral hemispheres, brain death is definite.

A patient admitted to the ICU following a car accident in which she suffered multiple traumatic injuries. She has a fever of 101F and complains of headache. When the physician tries to examine her eyes with a bright light, she jerks away. The nurse suspects meningeal irritation. What other signs would likely accompany this condition? Select all that apply. A) Nuchal rigidity B) Drainage of cerebrospinal fluid from the nose C) Drainage of cerebrospinal fluid from the ear D) Bruising over the mastoid areas E) Pain in the neck when the thigh is flexed and the leg is extended at the knee F) Involuntary flexion of the hips when the neck is flexed toward the chest

A) Nuchal rigidity E) Pain in the neck when the thigh is flexed and the leg is extended at the knee F) Involuntary flexion of the hips when the neck is flexed toward the chest

A patient with a suspected cervical spine fracture is undergoing computed tomography (CT) of the cervical spine for definitive diagnosis. During the procedure, what is the nursing priority? A) Protection of cervical spine stability B) Reassurance and anxiety reduction C) Explanation of the reason for the test D) Evaluation for allergic response to contrast medium

A) Protection of cervical spine stability

A patient is taking Phenytoin for treatment of seizures. Which statement by the patient requires you to re-educate the patient about this medication? A. "Every morning I take this medication with a full glass of milk with my breakfast." B. "I know it is important to have my drug levels checked regularly." C. "I will report a skin rash immediately to my doctor." D. "This medication can lower my body's ability to clot and fight infection."

A. "Every morning I take this medication with a full glass of milk with my breakfast." This medication should NOT be taken with milk products or antacids because it affects absorption. All the other options are correct

Which of the following statements are INCORRECT about exercise management for the diabetic patient? A. "I will check my blood glucose prior to exercise. If it is less than 200 I will eat a complex carb snack prior to exercising." B. "I plan on exercising for an extended period. So I will check my blood glucose prior, during, and after exercising." C. "My blood glucose is 268 and I have ketones in my urine. Therefore, I will avoid exercising today." D. All of the options are correct statements.

A. "I will check my blood glucose prior to exercise. If it is less than 200 I will eat a complex carb snack prior to exercising."

A patient is being educated on how to take their anti-thyroid medication. Which of the following statements are INCORRECT? A. "I will continue taking aspirin daily." B. "I will take this medication at the same time every day." C. "It may take a while before I notice that the medication is helping my condition." D. "I will avoid foods containing high levels of iodine."

A. "I will continue taking aspirin daily." The patient needs to be instructed NOT to take aspirin because it increases thyroid hormones. All the other statements are correct.

You are performing discharge teaching with a patient who is going home on Synthroid. Which statement by the patient causes you to re-educate the patient about this medication? A. "I will take this medication at bedtime with a snack." B. "I will never stop taking the medication abruptly." C. "If I have palpitations, chest pain, intolerance to heat, or feel restless, I will notify the doctor." D. "I will not take this medication at the same time I take my Carafate."

A. "I will take this medication at bedtime with a snack." Synthroid is best taken in the MORNING on an empty stomach. All the other statements are correct about taking Synthroid.

You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizure precautions: A. Oxygen and suction at bedside B. Bed in highest position C. Remove all pillows from the patient's head D. Have restraints on stand-by E. Padded bed rails F. Remove restrictive objects or clothing from patient's body G. IV access

A. Oxygen and suction at bedside E. Padded bed rails F. Remove restrictive objects or clothing from patient's body G. IV access The bed needs to be in the LOWEST position possible, a pillow should be underneath the patient's head to protect it from injury, AVOID using restraints (this can cause musculoskeletal damage).

You're assessing a patient who recently experienced a focal type seizure (partial seizure). As the nurse, you know that which statement by the patient indicates the patient may have experienced a focal impaired awareness (complex partial) seizure? A. "My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this." B. "I remember having vision changes, but it didn't last long." C. "I woke up on the floor with my mouth bleeding." D. "After the seizure I was very sleepy, and I had a headache for several hours."

A. "My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this." The patient will experience an alternation in consciousness (hence the name focal IMPAIRED awareness) AND will perform an action without knowing they are doing it called automatism like lip-smacking, rubbing the hands together etc. With a focal onset AWARE seizure (also called partial simple seizure) the patient is aware and will remember what happens (like vision changes etc.).

Which of the following values is considered normal for ICP? A. 0 to 15 mm Hg B. 25 mm Hg C. 35 to 45 mm Hg D. 120/80 mm Hg

A. 0 to 15 mm Hg Normal ICP is 0-15 mm Hg. Intracranial hypertension (IH) is a clinical condition that is associated with an elevation of the pressures within the cranium. The pressure in the cranial vault is measured in millimeters of mercury (mm Hg) and is normally less than 20 mm Hg.

A nurse is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse expect? (Select all that apply.) A. IV therapy with 0.45%sodium chloride B. Regular insulin C. Hydrocortisone sodium succinate D. Sodium polystyrene sulfonate E. Furosemide

A. 0.45% sodium chloride is hypotonic. Clients who have acute adrenal insufficiency are hyponatremic. Anticipate a prescription for a solution that contains 0.9% sodium chloride. B. Regular insulin: Clients who have acute adrenal insufficiency are hyperkalemic. Insulin is administered to shift potassium into the cells. C. Hydrocortisone sodium succinate: Hydrocortisone sodium succinate is administered as replacement therapy of both glucocorticoid and mineralocorticoid. D. Sodium polystyrene sulfonate: Clients who have acute adrenal insufficiency are hyperkalemic. Sodium polystyrene sulfonate is administered because it absorbs potassium. E. Furosemide: Loop and thiazide diuretics promote potassium excretion and are administered to treat hyperkalemia

A patient is scheduled to take 10 units of Humulin N at 1100. When is the patient most susceptible for hypoglycemia? A. 1900 B. 1300 C. 1130 D. 1500

A. 1900 Humulin N is an intermediate-acting insulin. The peak of this medication is 8 hours. Watch the YouTube video to learn the mnemonics on how to remember these times...very helpful.

The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse? A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal

A. 90 mmHg, normal CPP is calculated by the following formula: CPP=MAP-ICP. The patient's CPP is 90 and this is normal. A normal CPP is 60-100 mmHg.

You're assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.

A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal. All the patients are at risk except option C. Remember all the risk factors: illness (especially CNS types like bacterial meningitis), fever, electrolyte/metabolic issues (low blood sugar, acidosis etc), ETOH (alcohol) withdraw, brain injury, STROKE, congenital brain defects, tumors etc.

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider? A. Anticoagulant B. Plasma expanders C. H2 antagonists D. Muscle relaxants

A. Administer an anticoagulant to decrease the risk of developing a VTE. B. Administer plasma expanders to treat hypotension caused by the SCI. C. Administer H2 antagonists to decrease the complication of developing a gastric ulcer from stress. D. Muscle relaxants: Clarify with the provider the need for the client to receive muscle relaxants. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

Which of the following is a nursing PRIORITY when caring for a patient in Addisonian Crisis? A. Administering IV Solu-Cortef B. Checking blood glucose C. Monitoring low urine specific gravity D. Elevating the head of the bed

A. Administering IV Solu-Cortef Administering IV Solu-Cortef is a PRIORITY because if the patient does not immediately receive cortisol they will die. Once IV Solu-Cortef is administered symptoms will start to subside.

You're developing a nursing plan of care for a patient with neurogenic shock. As the nurse, you know that due to venous blood pooling from vasodilation a deep vein thrombosis can occur in this type of shock. A patient goal is that the patient will be free from the development of a deep vein thrombosis. Select all the nursing interventions below that can help the patient meet this goal: A. Perform range of motion exercises daily. B. Place a pillow underneath the patient knees as needed. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily.

A. Perform range of motion exercises daily. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily. Option B would impede blood flow and increase the risk of a DVT. The other options would help prevent a DVT.

Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? A. Ataxia and confusion B. Sodium depletion C. Tonic-clonic seizure D. Urinary incontinence

A. Ataxia and confusion A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. The neurotoxic effects are concentration dependent and can range from mild nystagmus to ataxia, slurred speech, vomiting, lethargy and eventually coma and death. Paradoxically, at very high concentrations, phenytoin can lead to seizures. Option B: Like all toxicologic exposures, the nature of the toxicity depends on fundamental pharmacologic principles: the route of exposure (oral versus parenteral), duration of exposure (acute overdose versus chronic), dosage, and the nature of metabolism (or deficiency thereof). Phenytoin displays its main signs of toxicity on the nervous and cardiovascular systems. Overdose on oral phenytoin causes mainly neurotoxicity and only very rarely causes cardiovascular toxicity. Option C: Symptoms correlate well with the unbound plasma phenytoin concentration. However, this laboratory value is seldom obtained. Seizures are very rare and usually occur at very high serum concentrations. The presence of seizures in a patient with suspected phenytoin overdose should prompt the search for other coingestants. Option D: Phenytoin does not cause urinary incontinence. Incontinence may occur during or after a seizure. Kidney disease can also lead to hypoalbuminemia as well as uremia which decreases the percentage of bound phenytoin in the plasma. Malnutrition, malignancy, and pregnancy are other causes for phenytoin toxicity in a patient on chronic therapy without any changes in dose.

A nurse is reviewing laboratory reports of a client who has HHS. Which of the following findings should the nurse expect? A. Blood pH 7.2 B. Blood osmolarity 350 mOsm/L C. Blood potassium 3.8 mg/dL D. Blood creatinine 0.8 mg/dL

A. Blood pH of 7.2 is an indication of diabetic ketoacidosis and is not an expected finding for HHS. B. Blood osmolarity 350 mOsm/L: A client who has HHS would have a blood osmolarity greater than 320 mOsm/L. C. Potassium 3.8 mEq/L is within the expected reference range. A client who has HHS would initially have a decreased blood potassium due to diuresis. D. Creatinine 0.8 mg/dL is within the expected reference range. A client who has HHS would have a blood creatinine of greater than 1.5 mg/dL, secondary to dehydration

You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all that apply: A. Blood pressure 69/38 B. Heart rate 170 bpm C. Blood pressure 250/120 D. Heart rate 29 E. Warm and dry extremities F. Cool and clammy extremities G. Temperature 104.9 'F H. Temperature 95 'F

A. Blood pressure 69/38 D. Heart rate 29 E. Warm and dry extremities H. Temperature 95 'F Hallmark signs and symptoms of neurogenic shock are: hypotension, bradycardia, hypothermia, warm/dry extremities (this is due to the vasodilation and blood pooling and will be found in the extremities).

Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater

A. Brain C. Cerebrospinal Fluid D. Blood Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

A. Condom catheter: Implement the noninvasive use of a condom catheter, because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder. B. Implement the intermittent urinary catheterization method for a client who has a flaccid bladder. C. Implement the Credé's method for a client who has a flaccid bladder. D. An indwelling urinary catheter is an invasive procedure. Do not implement this bladder management method for the client

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees

A. Coughing B. Sneezing D. Valsalva maneuver E. Vomiting These activities can increase ICP.

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

A. Decorticate posturing D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.

A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing DKA? (Select all that apply.) A. Drink 2 L fluids daily. B. Monitor blood glucose every 4 hr when ill. C. Administer insulin as prescribed when ill. D. Notify the provider when blood glucose is 200 mg/dL. E. Report ketones in the urine after 24 hr of illness.

A. Drink 2 L fluids daily: Drinking 2 L fluids daily can prevent dehydration if the client develops diabetic ketoacidosis. B. Monitor blood glucose every 4 hr when ill: Blood glucose tends to increase during illness. Blood glucose should be monitored every 4 hr. C. Administer insulin as prescribed when ill: Illness often causes blood glucose to increase. Regular doses of insulin should be administered. D. Notify the provider when blood glucose remains greater than 250 mg/dL despite treatment. E. Report ketones in the urine after 24 hr of illness: The provider should be notified if there are ketones in the urine after 24 hr of illness.

As part of the neurologic examination, the nurse instructs the patient to perform a Romberg test. What nursing action best provides for patient safety if the results are abnormal? A) Have suction equipment on hand B) Be prepared to catch the patient if he or she falls C) Have the patient perform the test in a seated position D) Have the patient perform the finger-to-nose test before this test

B) Be prepared to catch the patient if he or she falls

A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemic hyperosmolar state (HHS)? (Select all that apply.) A. Evidence of recent myocardial infarction B. BUN 35 mg/dL C. Takes a calcium channel blocker D. Age 77 years E. Daily insulin injections

A. Evidence of recent myocardial infarction: The client who has type 2 diabetes mellitus and had a myocardial infarction is at risk for developing HHS. This is due to the increased hormone production during illness or stress, which can stimulate the liver to produce glucose and decrease the effects of insulin. B. BUN 35 mg/dL: The client who has type 2 diabetes mellitus can be at risk for developing HHS when the BUN is 35 mg/dL because it is an indication of decreased kidney function and inability of the kidney to filter high levels of blood glucose into the urine. C. Takes a calcium channel blocker: A calcium channel blocker is one of several medications that increase the risk for HHS in a client who has type 2 diabetes mellitus. D. Age 77 years: The older adult client is at risk for developing type 2 diabetes mellitus and can be unaware of associated manifestations, increasing the risk for HHS. E. Taking insulin does not increase the risk for HHS. When a client is experiencing hyperglycemia, insulin prevents the client from developing DKA.

A nurse is reviewing the medical record for a client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? A. Administer an IV infusion of regular insulin at 0.3 unit/kg/hr. B. Administer a slow IV infusion of 3% sodium chloride. C. Rapidly administer an IV infusion of 0.9% sodium chloride. D. Add glucose to the IV infusion when blood glucose is 350 mg/dL.

A. Expect to administer an IV infusion of regular insulin at 0.1 unit/kg/hr to gradually lower blood glucose to prevent cerebral edema. B. Expect to administer a 3% sodium chloride solution to a client who has hyponatremia. C. Rapidly administer an IV infusion of 0.9% sodium chloride: Expect to rapidly administer an IV infusion of 0.9% sodium chloride, an isotonic fluid, as prescribed to maintain blood perfusion to vital organs. The initial infusion for a client who has an elevated sodium would be 0.45% sodium chloride. D. Add glucose to the IV infusion when the blood glucose is 250 mg/dL, not 350 mg/dL, to prevent hypoglycemia and minimize cerebral edema.

A patient with hypothyroidism is having pain 6 on 1-10 scale in the right hip due to recent hip surgery. Which of the following medications are NOT appropriate for this patient? Select all that apply: A. Fentanyl B. Tylenol C. Morphine D. Dilaudid

A. Fentanyl C. Morphine D. Dilaudid Patients who have hypothyroidism are very sensitive to narcotics and should take NON-NARCOTICS for pain relief. Fentanyl, Morphine, and Dilaudid are all narcotics, whereas, Tylenol is not.

A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply: A. Headache B. Low blood glucose C. Sweating D. Flushed below site of injury E. Pale and cool above site of injury F. Hypertension G. Slow heart rate H. Stuffy nose

A. Headache C. Sweating F. Hypertension G. Slow heart rate H. Stuffy nose All of these are signs and symptoms of autonomic dysreflexia. The patient will have flushing above site of injury due to vasodilation from parasympathetic activity, BUT will be pale and cool below site of injury due to vasoconstriction occurring below the site of injury for the sympathetic response reflex.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A. Hemorrhagic skin rash B. Edema C. Cyanosis D. Dyspnea on exertion

A. Hemorrhagic skin rash disseminated intravascular coagulation (DIC) is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition. Disseminated intravascular coagulation (DIC) can be defined as a widespread hypercoagulable state that can lead to both microvascular and macrovascular clotting and compromised blood flow, ultimately resulting in multiple organ dysfunction syndrome or MODS. As this process begins consuming clotting factors and platelets in a positive feedback loop, hemorrhage can ensue, which may be the presenting symptom of a patient with DIC.

What is the BEST position for a patient experiencing autonomic dysreflexia? A. High Fowler's with legs lowered B. Low Fowler's with legs lowered C. Semi-Fowler's with legs at heart level D. Prone

A. High Fowler's with legs lowered The patient should be in high Fowler's (90 degrees) with the legs lowered. This will allow gravity to cause blood to pool in the lower extremities and help decrease blood pressure.

A nurse is caring for a client 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

A. Hyperglycemia is not an adverse effect of mannitol. B. Hyponatremia: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia. C. Hypovolemia is an adverse effect of mannitol and should be monitored. D. Polyuria is an adverse of mannitol and should be monitored

A patient was recently discharged home after being treated for Addison's Disease. The patient states they were unable to get their prescription for Prednisone filled after they were discharged from the hospital. The patient complains of pain in their abdomen, legs, and lowers back and is very weak. On assessment, you note the patient's blood pressure is 70/32, blood glucose 63, sodium 118, and potassium level 6.0. Which medication do you anticipate will be ordered by the doctor for this patient? A. IV Solu-Cortef B. PO Hydrocortisone C. IV Morphine D. PO Prednisone

A. IV Solu-Cortef

A patient is being discharged after recovering from Addisonian Crisis. Which of the following statements by the patient causes you to re-educate the patient about this condition? A. "I will monitor my stress levels closely." B. "I can stop taking my medication once I feel better." C. "I am going to wear a Medic-Alert bracelet." D. "I will make sure I perform hand hygiene regularly and avoid sick people."

B. "I can stop taking my medication once I feel better."

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure(ICP). Which of the following actions should the nurse plan to take? (Select all that apply.) A. Implement seizure precautions. B. Perform neurologic checks four times a day. C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television. E. Monitor for impaired extraocular movements. F. Encourage the client to cough frequently.

A. Implement seizure precautions: The client is at risk for seizures due to possible increased ICP. Therefore, the nurse should implement seizure precautions to reduce the client's risk for injury. B. The nurse should perform neurologic checks at least every 2 hr for a client who is at risk for increased ICP. C. The nurse should avoid administering opioids to a client who is at risk for increased ICP. Opioids can mask changes in the client's level of consciousness. D. Turn off room lights and television: The nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP. E. Monitor for impaired extraocular movements: The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP. F. The nurse should instruct the client to avoid coughing because this action can cause increased ICP.

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 nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.

A. Keep neck stabilized: The greatest risk to the client 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. B. Insertion of a nasogastric tube is not the priority nursing action at this time. C. Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time. D. Establishing IV access for fluid replacement is important but not the priority nursing action at this time.

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.

A. Keep the client in a side-lying position: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth keeping the airway patent. B. The nurse should document the duration of the seizure in the client's medical record, but there is another action that the nurse should take first. C. The nurse should reorient the client to the environment because the client can feel confused, but there is another action that the nurse should take first. D. The nurse should provide client hygiene if the client experienced incontinence during the seizure, but there is another action that the nurse should take first.

In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring: A. Loss of vasomotor tone B. Increase systemic vascular resistance C. Decrease in cardiac preload D. Increase in cardiac afterload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities

A. Loss of vasomotor tone C. Decrease in cardiac preload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities Massive vasodilation is occurring in the body and this is due to the loss of vasomotor tone (remember the sympathetic nervous system loses its ability to stimulate nerves that regular the diameter of vessels....so vessels are relaxed). This will DECREASE (NOT increase) systemic vascular resistance (which will decrease cardiac afterload) and the blood pressure will fall. Furthermore, there is pooling of venous blood in the extremities because there isn't any pressure to push it back to the heart. This will cause a decrease in venous blood return to the heart. When this occurs it will decrease cardiac preload (the amount the ventricle stretch at the end of diastole). All of this together will decrease the amount of blood the heart can pump per minute....hence the cardiac output and shock will occur.

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

A. Monitor for neurogenic shock, which is a response of the sympathetic nervous system of a client who has a SCI. However, another complication is the priority. B. Monitor for a paralytic ileus, which is a complication immediately following a SCI. However, another complication is the priority. C. Monitor for a stress ulcer, which is a response to changes caused from the SCI. However, another complication is the priority. D. Respiratory compromise: When using the airway, breathing, and circulation (ABC) approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

A patient is receiving radioactive iodine as treatment for Grave's Disease. Which of the following are common side effects of the treatment? Select all that apply: A. Nausea B. Taste changes C. Excessive saliva D. Swollen salivary glands

A. Nausea B. Taste changes D. Swollen salivary glands

You administered 5 units of Humalog at 0800. What is the ONSET and DURATION of this medication? A. Onset: 15 minutes, Duration: 3 hours B. Onset: 2 hours, Duration: 16 hours C. Onset: 30 minutes, Duration: 1 hour D. Onset: 2 hours, Duration: 24 hours

A. Onset: 15 minutes, Duration: 3 hours Humalog is a rapid-acting insulin. It has an onset: 15 minutes and duration: 3 hours Watch the YouTube video to learn the mnemonics on how to remember these times...very helpful.

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply.) A. Place client in supine position. B. Flex client's hip and knee. C. Place hands behind the client's neck. D. Bend client's head toward chest. E. Straighten the client's flexed leg at the knee.

A. Place client in supine position: The nurse should place the client in supine position when assessing for Brudzinski's sign. B. The nurse should flex the client's hip and knee when assessing for Kernig's sign. C. Place hands behind the client's neck: The nurse should place her hands behind the client's neck when assessing for Brudzinski's sign, in order to flex the client's neck. D. Bend client's head toward chest: The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign. E. The nurse should straighten the client's flexed leg at the knee when assessing for Kernig's sign.

A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.

A. Provide privacy: The nurse should implement privacy to minimize the client's embarrassment. B. Ease the client to the floor if standing: The nurse should ease the client to the floor to prevent falling and injury. C. Move furniture away from the client: The nurse should move the furniture away from the client to prevent injury. D. Loosen the client's clothing: The nurse should loosen the client's clothing to minimize restriction of movement. E. Protect the client's head with padding: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. The nurse should not restrain the client. Restraint can increase the client's risk for injury or more seizure activity.

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

A. Quadriplegia with gross arm movement and diaphragmatic breathing. A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Cervical spine injuries, although uncommon, can result in significant and long-term disability. The cervical spine encompasses seven vertebrae and serves as a protection to the spinal cord. C5 to C7 are responsible for deep tendon reflexes of the biceps, brachioradialis, and triceps respectively. C5 controls shoulder abduction with the aid of C4 and elbow flexion with the aid of C6. C6 to C7 are responsible for elbow extension, wrist extension, and flexion. Option B: Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. C1 to C3 are responsible for movements of the head, the dermatome of C2 is responsible for sensation to the dorsal aspect of the head, and C3 is responsible for sensation to the lateral aspects of the face and posterior portion of the head. C3 to C4 contribute to breathing by controlling the muscles of the diaphragm. Option C: Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. This term refers to impairment or loss of motor and/or sensory function in the thoracic, lumbar or sacral (but not cervical) segments of the spinal cord, secondary to damage of neural elements within the spinal canal. With paraplegia, arm functioning is spared but the trunk, legs and pelvic organs may be involved depending on the level of injury. Option D: Injuries below L2 cause paraplegia and loss of bowel and bladder control. A spinal cord injury may interrupt communication between the nerves in the spinal cord that control bladder and bowel function and the brain, causing incontinence. This results in bladder or bowel dysfunction that is termed "neurogenic bladder" or "neurogenic bowel."

You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary

A. Rectal This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.

A patient who is having a tonic-clonic seizure is prescribed Phenobarbital. During administration of this drug, it is important the nurse monitors for? (Select all that apply) A. Respiratory depression B. Hypertension C. Disseminated intravascular clotting D. Hypotension E. Fever

A. Respiratory depression D. Hypotension This medication stimulates the GABA receptors and helps with inhibitory neurotransmission. It can lead to respiratory depression and hypotension, therefore, it is very important the nurse monitors the patient for this.

Which of the following foods below should a patient experiencing a thyroid storm avoid? Select all that apply: A. Shrimp B. Milk C. Hard boiled eggs D. Seaweed (Kelp) E. Broccoli F. Peas

A. Shrimp B. Milk C. Hard boiled eggs D. Seaweed (Kelp) Foods high in iodine are seafoods like shrimp, seaweed, and dairy/eggs Other high iodine foods: Cod, any dairy products, iodized salt, tuna, prunes, lima beans

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A. Side-lying, with legs pulled up and head bent down onto the chest. B. Side-lying, with a pillow under the hip. C. Prone, in a slight Trendelenburg's position. D. Prone, with a pillow under the abdomen.

A. Side-lying, with legs pulled up and head bent down onto the chest. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae. The positioning of the patient in either a lateral recumbent position or sitting position may be used. The lateral recumbent position is preferred as it will allow an accurate measurement of opening pressure, and it also reduces the risk of post-lumbar puncture headache. Option B: The patient should be instructed to assume the fetal position, which involves the flexion of the spine. It may be helpful to instruct the patient to flex their back "like a cat." By doing so, the space between the spinous processes increases, allowing for easier needle insertion. Option C: To help keep the needle at the midline during insertion, the lumbar spine should be perpendicular to the table in the sitting position and parallel to the table if in the recumbent position. Lumbar puncture is one of the most commonly performed procedures in the emergency department. It is used in the diagnosis of potentially life-threatening diseases such as meningitis and subarachnoid hemorrhage. Option D: Lumbar puncture is a commonly performed procedure in the emergency department and can be of great clinical importance when diagnosing potentially lethal diseases such as meningitis and subarachnoid hemorrhage. With proper preparation, technique, and care, the risks of complications can be significantly reduced.

A nurse is preparing to receive a client from the PACU who is postoperative following a thyroidectomy. The nurse should ensure that which of the following equipment is available? (Select all that apply.) A. Suction equipment B. Humidified oxygen C. Flashlight D. Tracheostomy tray E. Chest tube tray

A. Suction equipment: The client can require oral or tracheal suctioning. Ensure that suctioning equipment is available. B. Humidified oxygen: The client can require supplemental oxygen due to respiratory complications. Humidified oxygen thins secretions and promotes respiratory exchange. This equipment should be available. C. A flashlight is used to measure the reaction of the pupils to light for a client who has an intracranial disorder. Checking pupil reaction with a flashlight is not indicated for this client. D. Tracheostomy tray: The client can experience respiratory obstruction. A tracheostomy tray should be available at the bedside. E. A chest tube tray would be used for a client who develops a hemothorax or pneumothorax. This is not an expected complication of a thyroidectomy. This equipment is not indicated for this client.

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? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room. C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

A. Suctioning increases ICP and should be performed only when indicated. B. Decrease the noise level in the client's room: Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. C. Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bed should be raised to at least 30°, but the head should be maintained in an upright, neutral position. D. Administer a stool softener: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. E. Overhydration carries the risk of increasing ICP and should be avoided. Monitor fluid and electrolyte levels closely for the client who has increased ICP.

A patient is receiving radioactive iodine treatment for hyperthyroidism. What will you include in your patient education to this patient about this type of treatment? A. Taste changes and swollen salivary glands B. Constipation C. Excessive thirst D. Sun protection

A. Taste changes and swollen salivary glands

A nurse is planning to teach a client who is being evaluated for Addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should base the instructions on which of the following? A. The ACTH stimulation test measures the response by the kidneys to ACTH. B. In the presence of primary adrenal insufficiency, plasma cortisol levels rise in response to administration of ACTH. C. ACTH is a hormone produced by the pituitary gland. D. The client is instructed to take a dose of ACTH by mouth the evening before the test.

A. The ACTH stimulation test measures the response by the adrenal glands to ACTH. B. In the presence of primary adrenal insufficiency, plasma cortisol levels do not rise in response to administration of ACTH. C. ACTH is a hormone produced by the pituitary gland: Secretion of corticotropin-releasing hormone from the hypothalamus prompts the pituitary gland to secrete ACTH. D. ACTH is administered IV during the testing process, and plasma cortisol levels are measured 30 min and 1 hr after the injection.

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

A. The Glasgow Coma Scale is important. However, another assessment is the priority. B. Assessment of cranial nerve function is important. However, another assessment is the priority. C. Oxygen saturation: Using the airway, breathing, and circulation (ABC) priority-setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs. D. Assessment of pupillary response is important. However, another assessment is the priority

A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply.) A. Anorexia B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia

A. The client who has hyperthyroidism has an increased metabolic rate, resulting in increased hunger. B. Heat intolerance: Hyperthyroidism increases the client's metabolism, causing heat intolerance. C. Diarrhea is an expected finding for the client who has hyperthyroidism. D. Palpitations: Hyperthyroidism increases the client's metabolism, causing palpitations. E. Weight loss: Hyperthyroidism increases the client's metabolism, causing weight loss. F. Hyperthyroidism increases the client's metabolism, causing tachycardia.

A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking an antacid when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication.

A. The nurse does not need to instruct the client to consider taking an antacid, because phenytoin does not cause any gastrointestinal adverse effects. B. The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. Take the medication at the same time every day: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. The nurse should instruct the client to have periodic blood tests to determine the therapeutic level of phenytoin.

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics. B. Implement droplet precautions. C. Initiate IV access. D. Decrease bright lights

A. The nurse should administer antibiotics to stop the micro-organisms from multiplying, but this is not the priority action. B. Implement droplet precautions: When using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others. C. The nurse should initiate IV access to allow IV medication and fluid administration, but this is not the priority action. D. The nurse should decrease bright lights because of the client's sensitivity to light, but this is not the priority action

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less." . B. "You should avoid the use of CT scans with contrast.". C. "You should place a magnet over the implantable device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain management."

A. The nurse should instruct the client to avoid using a microwave, regardless of wattage, which can affect the function of the stimulator. B. The nurse should instruct the client to avoid MRIs, which can affect the function of the stimulator. C. "You should place a magnet over the implantable device when you feel an aura occurring.": The nurse should instruct the client to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. The nurse should instruct the client to avoid the use of ultrasound diathermy for pain management because of its effect on the function of the stimulator

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Monitor for bradycardia. B. Provide an emesis basin at the bedside. C. Administer antipyretic medication. D. Perform a skin assessment. E. Keep the head of the bed flat.

A. The nurse should plan to monitor for tachycardia when a client has meningitis. B. Provide an emesis basin at the bedside: The nurse should provide an emesis basin at the bedside because the client who has meningitis can have nausea and vomiting. C. Administer antipyretic (anti-fever) medication: The nurse should plan to administer antipyretic medication for fever to a client who has meningitis. D. Perform a skin assessment: The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis. E. The nurse should elevate the head of the client's bed 30° to promote venous drainage from the head and prevent increased ICP.

A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection. B. The vaccine is administered in a series of four doses. C. The vaccine is recommended for adolescents before starting college. D. The vaccine is initially given at 2 months of age

A. The pneumococcal vaccine is primarily indicated to reduce the risk of respiratory infection. However, it also reduces the risk of CNS infection. B. The HIB vaccine is administered to infants in a series of four doses. C. The vaccine is recommended for adolescents before starting college: The nurse should identify that the meningococcal vaccine is recommended for adolescents prior to starting college due to the increased risk for infection in communal living facilities. D. The initial dose of the HIB vaccine is recommended for infants at 2 months of age.

A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. Which of the following findings is indicative of thyroid crisis? (Select all that apply.) A. Bradycardia B. Hypothermia C. Dyspnea D. Abdominal pain E. Mental confusion

A. When thyroid crisis occurs, the client experiences an extreme rise in metabolic rate, which results in tachycardia. B. When thyroid crisis occurs, the client experiences an extreme rise in metabolic rate, which results in a high fever. C. Dyspnea: Excessive levels of thyroid hormone can cause the client to experience dyspnea. D. Abdominal pain: When thyroid crisis occurs, the client can experience gastrointestinal conditions (vomiting, diarrhea, and abdominal pain). E. Mental confusion: Excessive thyroid hormone levels can cause the client to experience mental confusion.

A nurse is providing instructions to a client who has Graves' disease and has a new prescription for propranolol. Which of the following information should the nurse include? A. "An adverse effect of this medication is jaundice." B. "Take your pulse before each dose." C. "The purpose of this medication is to decrease production of thyroid hormone." D. "You should stop taking this medication if you have a sore throat."

A. Yellowing of the skin is an adverse effect of methimazole. B. "Take your pulse before each dose.": Propranolol can cause bradycardia. The client should take their pulse before each dose. If there is a significant change, they should withhold the dose and consult the provider. C. The purpose of propranolol is to suppress tachycardia, diaphoresis, and other effects of Graves' disease. D. Sore throat is not an adverse effect of this medication. The client should not discontinue taking this medication because this action can result in tachycardia and dysrhythmias

The nurse is caring for a client diagnosed with epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93 percent. 4. Perform deep Nasal suction every 2 hours. 5. Administer mild sedative.

Administer stool softeners daily. Ensure that pulse oximeter reading is higher than 93 percent. Administer mild sedative. Stool softeners are initiated to prevent the Bell sell the maneuver which increases ICP. oxygen saturation higher the 93 percent ensures oxygenation of the brain tissues. decreasing oxygen levels increase cerebral edema. mild sedative will reduce the clans agitation. Strong narcotics would not be administered because they decrease the clients loc.

A patient was involved in a fight in which he was struck in the back of the head with a blunt object. Scalp laceration is immediately evident. The nurse suspects cerebral edema and ischemia. On CT scan, it appears that he has contusions and a fractured skull. On neurological assessment, the nurse finds evidence of concussion, as the patient demonstrates short-term memory impairment. Of these findings, which are secondary brain injuries? Select all that apply. A) Scalp laceration B) Cerebral edema C) Ischemia D) Contusions E) Fractured skull F) Concussion

B) Cerebral edema C) Ischemia

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death

An intact brainstem Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or disconjugate eye movements indicate brainstem damage.

The nurse is determining which patients should have corneal reflex assessments completed during morning care. For which patients would assessing this reflex be appropriate? (Select all that apply.) An unconscious patient Anyone over the age of 50 A patient with a head injury A patient who wears contact lenses A patient with spinal cord trauma

An unconscious patient A patient with a head injury A patient who wears contact lenses Rationale: The corneal reflex may be affected in patients who are unconscious or have a head injury. The reflex may be absent or decreased in patients who wear contact lenses. Being over the age of 50 does not cause loss of the corneal reflex. The level of the injury would determine if the corneal reflex would be affected in the patient with spinal cord trauma

The nurse is planning care for a patient with an acute SCI. According to best practices, which medications should the nurse prepare to administer to this patient? (Select all that apply.) Analgesics Antibiotics Vasopressors Antihistamines Corticosteroids

Analgesics Vasopressors Corticosteroids Rationale: Analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) and narcotics are administered to reduce pain. Vasopressors are used in the immediate acute care phase to treat bradycardia or hypotension due to spinal and neurogenic shock. Corticosteroids may be used to decrease or control inflammation and edema of the cord. Antibiotics and antihistamines are not indicated in the acute care of a patient with a SCI.

The nurse is documenting that a patient is demonstrating decorticate posturing. What does this statement indicate about the patient's physical posture? In supine position, spine extended, legs extended In prone position with arms and knees sharply flexed Arms close to sides, elbows and wrists flexed, legs extended Neck extended, arms extended and pronated, feet plantar flexed

Arms close to sides, elbows and wrists flexed, legs extended Rationale: In decorticate posturing the upper arms are close to the body; the elbows, wrists, and fingers are flexed; and the legs are extended with internal rotation. In decerebrate posturing the neck is extended, the arms are extended and pronated, and the feet are plantar flexed. The term decorticate is not used to describe posture changes that are associated with either the supine or prone positions

A patient with a suspected skull fracture is observed to have raccoon eyes, or bilateral periorbital bruising. What other symptom does the nurse expect? A) Positive Battles sign B) Cerebrospinal fluid rhinorrhea C) Cerebrospinal fluid otorrhea D) Maxillarycranial separation

B) Cerebrospinal fluid rhinorrhea

A nurse is assessing a patient recovering from a posterior cervical laminectomy for manifestations of spinal cord compression. How should this assessment be conducted? Ask the patient to wiggle his or her toes. Ask the patient to grip the nurse's hands. Use a stethoscope to auscultate heart sounds. Use a reflex hammer to assess Babinski's reflex.

Ask the patient to grip the nurse's hands. Rationale: To monitor for signs of nerve root compression after a cervical laminectomy, the nurse should assess hand grips, arm strength, the ability to move the fingers, and the ability to detect touch. Wiggling the toes would be used to assess for nerve compression after a lumbar laminectomy. Auscultation of heart sounds will not detect cervical root compression after a cervical laminectomy. A reflex hammer is not used to assess for a Babinski reflex.

The nurse is preparing to assess a patient's neurologic system. Which assessment technique is not a part of this physical assessment? Palpation Percussion Inspection Auscultation

Auscultation Rationale: The neurologic system is assessed through inspection, palpation, and percussion (by using a reflex hammer). Auscultation is not used in assessing the neurologic system.

the client diagnosed with a mild concussion is being discharged from the emergency department. which discharge instruction should the nurse teach the clients significant other? 1. Awake in the client every 2 hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every 3 to 4 hours.

Awake in the client every 2 hours. Awakening the client every 2 hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety, all signs a post concussion syndrome ,which would warrant a return to the emergency department.

A patient is preparing to undergo magnetic resonance imaging for possible diagnosis of cerebral infarction. What is the nursing priority in preparing the patient for this diagnostic study? A) Checking the patients history for renal insufficiency, which could complicate use of a contrast medium. B) Confirming that the patient does not have any ferrous surgical clips or implants. C) Determining whether the patient is on anticoagulant therapy, which would be a contraindication. D) Preparing an 18-gauge needle for insertion.

B) Confirming that the patient does not have any ferrous surgical clips or implants.

A patient involved in a snowmobile accident struck a tree and sustained a fractured vertebra at C4. She demonstrates signs of ischemic areas near the injury, along with hypoperfusion, microscopic hemorrhage, and edema. The nurse observes signs of concussion, including loss of consciousness. Which of the following are considered secondary injuries? Select all that apply. A) Fractured vertebra B) Cord ischemia C) Hypoperfusion D) Microscopic hemorrhage E) Edema F) Concussion

B) Cord ischemia C) Hypoperfusion D) Microscopic hemorrhage E) Edema

A patient with traumatic brain injury is being assessed. This patient demonstrates gross defects in visual acuity on reading a Snellen eye chart. Which cranial nerve is most likely damaged? A) Cranial nerve I B) Cranial nerve II C) Cranial nerve III D) Cranial nerve IV

B) Cranial nerve II

The patient has been in a motor vehicle crash and is in the critical care unit with severe brain injury. She is comatose but when painful stimuli are applied she extends, adducts, and hyperpronates her upper extremities and has plantarflexion of the feet. This action is called what? A) Decorticate posturing B) Decerebrate posturing C) Clonic-tonic activity D) Flacidity

B) Decerebrate posturing

A patient with a traumatic brain injury is given IV phenytoin to prevent seizures. Three days after the drug is started, the patient develops a red, vesicular rash on her trunk. What is the most appropriate collaborative intervention? A) Administer an antihistamine. B) Discontinue phenytoin. C) Evaluate for contact dermatitis. D) Place in contact isolation.

B) Discontinue phenytoin.

A nurse is assessing the plantar reflex in a patient. Which of the following results would indicate abnormal response and a possible lesion in the pyramidal tract? Select all that apply. A) Plantar flexion of all toes B) Dorsiflexion of the big toe with fanning of the other toes C) No response at all D) Dorsiflexion of the big toe without fanning of the other toes E) Ticklishness

B) Dorsiflexion of the big toe with fanning of the other toes D) Dorsiflexion of the big toe without fanning of the other toes

A patient recovering from a partial spinal cord lesion is experiencing muscle spasticity. Relative to this complication, what is the nursing priority? A) Monitor neurologic status every 4 hours B) Ensure compliance with exercise program C) Medicate often for pain and discomfort D) Emphasize nutritional balance

B) Ensure compliance with exercise program

Which statements are TRUE about autonomic dysreflexia? Select all that apply: A. "Autonomic dysreflexia is an exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury." B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension." C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury." D. "The first-line of treatment for autonomic dysreflexia is an antihypertensive medication."

B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension." C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury." Option A is false, it should say: Autonomic dysreflexia is an exaggerated reflex response by the SYMPATHETIC (NOT parasympathetic) nervous system that results in severe hypertension due to a spinal cord injury. Option D is false because medications are used only if the blood pressure is not decreasing or the cause cannot be determined.

You're developing discharge instructions to the parents of a child who experiences atonic seizures. What information below is important to include in the teaching? A. "This type of seizure is hard to detect because the child may appear like he or she is daydreaming." B. "Be sure your child wears a helmet daily." C. "It is common for the child to feel extremely tired after experiencing this type of seizure." D. "Avoid high fat and low carbohydrate diets."

B. "Be sure your child wears a helmet daily." This type of seizure leads to a sudden loss of muscle tone. The patient will go limp and fall, which when this happens the head is usually the first part of the body to hit the floor or an object nearby. It is important the child wears a helmet daily to protect their head from injury. Option A is a characteristic of an absence seizure. Option C is a characteristic of a tonic-clonic seizure during the post ictus stage. And option D is wrong because some patients benefit from this type of diet known as the ketogenic diet.

Which of the following patient statements about the diabetic diet regime is correct? A. "I'll try to consume about 20% carbs and 40% fats on a daily basis." B. "Foods that are high in mono and poly fats are avocados, olives, and nuts." C. "Meats increase the glycemic index; therefore, I should only consume 5% of them on a daily basis." D. "I should completely avoid starchy vegetables like potatoes and corn."

B. "Foods that are high in mono and poly fats are avocados, olives, and nuts."

As the nurse educating the patient about Grave's Disease, which of the following statements by the patient ensures the patient understood the education about their condition? A. "I could experience myxedema coma, which is life-threatening, if I abruptly stop taking my antithyroid medication." B. "Grave's disease is due to an excessive amount of thyroid hormone in the body." C. "I will be sure to eat a lot of kelp because it helps with decreasing thyroid hormone levels." D. "If I have pain I will only take aspirin."

B. "Grave's disease is due to an excessive amount of thyroid hormone in the body." Option A is wrong because myxedema coma is a complication of HYPOthyroidism, and if the patient abruptly stops taking their antithyroid medication they are at risk for THYROID STORM. Kelp (seaweed) and Aspirin should be avoided in Grave's disease because they both cause increased T3 and T4 production.

A patient is started on Tapazole (Methimazole) for treatment of Grave's Disease. Which statement by the patient indicates they understood your teaching about this medication? A. "If I experience fast heart, excessive sweating, or fever, I will notify the doctor immediately because I may be experiencing toxicity of the medication." B. "I know it may take a while before I feel relief of symptoms, therefore, I will never abruptly stop taking my medication." C. "This medication can cause high blood glucose." D. "I will make sure my diet is rich in foods containing iodine."

B. "I know it may take a while before I feel relief of symptoms, therefore, I will never abruptly stop taking my medication." Toxicity of Tapazole (an antithyroid medication) would include bradycardia, hypothermia, hypotension (signs and symptoms of HYPOthyroidism) etc. This medication is not known to cause high blood glucose, and the patient should avoid foods high in iodine because this causes an increased production of thyroid hormones.

A patient with Type 2 Diabetes is started on the medication Glyburide. Which of the following statements by the patient causes concern? A. "I will monitor my blood glucose regularly because I know this medication can cause a low blood sugar." B. "I will consume no more than 8 oz. of alcohol per week." C. "I will continue monitoring my diet and participating in exercise while taking this medication." D. "This medication works by stimulating the beta cells in the pancreas to make insulin."

B. "I will consume no more than 8 oz. of alcohol per week." Glyburide is a sulfonylureas diabetic medication and a patient should NEVER consume alcohol while taking this medication because it can cause severe hypoglycemia.

You're educating a 25-year-old female about possible triggers for seizures. Which statement requires you to re-educate the patient about the triggers? A. "I'm at risk for seizure activity during my menstrual cycle." B. "I will limit my alcohol intake to 2 glasses of wine per day." C. "It's important I get plenty of sleep." D. "I will be sure to stay hydrated, especially during hot weather."

B. "I will limit my alcohol intake to 2 glasses of wine per day." The patient should avoid all alcohol because it can lead to a seizure. Hormone shifts (menstrual cycle, ovulation, pregnancy) sleep deprivation, and dehydration can lead to a seizure.

You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg

B. 60-100 mmHg This is a normal CPP. Option A represents a normal intracranial pressure.

Which patient below is at MOST risk for developing a condition called autonomic dysreflexia? A. A 24-year-old male patient with a traumatic brain injury. B. A 15-year-old female patient with a spinal cord injury at C7. C. A 35-year-old male patient with a spinal cord injury at L6. D. A 42-year-old male patient recovering from a hemorrhagic stroke.

B. A 15-year-old female patient with a spinal cord injury at C7. Patients who are at MOST risk for developing autonomic dysreflexia are patients who've experienced a spinal cord injury at T6 or higher...this includes C7. L6 is below T6, and traumatic brain injury and hemorrhagic stroke does not increase a patient risk of AD.

You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply: A. A 36-year-old with a spinal cord injury at L4. B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.

B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. Any patient who has had a cervical or upper thoracic (above T6) spinal cord injury, receiving spinal anesthesia, or taking drugs that affect the autonomic or sympathetic nervous system is at risk for developing neurogenic shock.

Which patient is most at risk for Thyroid Storm? A. A 60 year old female who reports not taking Synthroid regularly. B. A 45 year old male who has not been taking Tapazole as ordered and is experiencing diabetic ketoacidosis. C. A 6 year old with an allergy to iodine. D. A 25 year old female who is pregnant with her 4th child and is experiencing eczema.

B. A 45 year old male who has not been taking Tapazole as ordered and is experiencing diabetic ketoacidosis. The red flag in this option is "not been taking Tapazole" and is experiencing "DKA". This indicates the patient has hyperthyroidism (Tapazole is an antithyroid medication) and this already puts him at risk for thyroid storm. Then DKA is another added stress on the body that can send him into thyroid storm. All the other options are either incorrect or the patient is at risk for myxedema coma (a complication of HYPOTHYROIDISM).

Which of the following patients are MOST at risk for developing myxedema coma? A. A 28 year old female who is prescribed Methimazole. B. A 75 year old female who is taking Lithium and reports missing several doses of Synthroid. C. A 69 year old male experiencing nausea and vomiting for 4 days. D. A 55 year old male with a history of diabetes and is insulin dependent.

B. A 75 year old female who is taking Lithium and reports missing several doses of Synthroid. Elderly females are at most risk for myxedema coma. In addition, Lithium decreases thyroid hormone and if the patient has missed several doses of Synthroid (used to treat HYPOthyroidism) this puts them at the greatest risk of myxedema coma.

Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.

B. A patient who is admitted with a traumatic brain injury. Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.

Which of the following patients is MOST at risk for developing Addisonian Crisis? A. A patient who is post-opt day 2 from thyroid surgery. B. A patient who is post-opt day 2 from an adrenalectomy. C. A patient with Addison's Disease who reports taking Prednisone regularly. D. A patient who is having gastrointestinal surgery.

B. A patient who is post-opt day 2 from an adrenalectomy. Patients who have had removal of the adrenal glands (adrenalectomy) are MOST at risk for low levels of cortisol (since the gland that produces the hormone has been removed). A patient with Addison's Disease is at risk if they have NOT being taking Prednisone regularly.

Tonya Walton is a 29-year-old female. She was involved in a car crash 12 hours before her admission 5 days earlier. She developed a headache, drowsiness, confusion, and pupil enlargement several hours after the crash. Following an MRI, Ms. Walton underwent intracranial surgery to evacuate a subdural hematoma. She has been complaining of a headache that has increased in intensity from 2 to 6 on a scale of 1 to 10 on the previous shift. She received two Tylenol ES tabs 1 hour ago. BP was 140-150 mmHg systolic and 90-100 mmHg diastolic for most of the shift. Her BP at the time the Tylenol was administered was 175/115 mmHg. She has not experienced any changes in her neuro assessment except for the increasing headache and blood pressure elevation. If you reevaluated Ms. Walton and her headache pain had not decreased, what should be your next priority? A. Reposition Ms. Walton on her left side with the head of the bed flat. B. Call the physician about patient report of increasing headache. C. Decrease stimuli in the room by darkening the room and limiting noise. D. Check the prn orders to evaluate if a stronger pain medication has been ordered.

B. Call the physician about patient report of increasing headache. Rationale: Increased headache that is not controlled with medication indicates increased intracranial pressure and must be reported to the physician.

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose. B. Cloudy CSF, elevated protein, and decreased glucose. C. Clear CSF, elevated protein, and decreased glucose. D. Clear CSF, decreased pressure, and elevated protein.

B. Cloudy CSF, elevated protein, and decreased glucose. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels. Option A: Patients presumed to have bacterial meningitis should receive a lumbar puncture to obtain a cerebrospinal fluid (CSF) sample. The CSF should be sent for Gram stain, culture, complete cell count (CBC), and glucose and protein levels. Bacterial meningitis typically results in low glucose and high protein levels in the cerebrospinal fluid. Option C: As CSF glucose levels are dependent on circulating serum glucose levels, the CSF to serum glucose ratio is considered a more reliable parameter for the diagnosis of acute bacterial meningitis than absolute CSF glucose levels. A neutrophil predominance on cell count would be expected. Option D: A clear CSF is normal. Symptoms are similar to aseptic meningitis, but clinical presentation is much more severe. Additional symptoms include altered mental status, seizures, and focal neurologic signs. Diagnosis is also possible via LP. CSF is usually cloudy in appearance, with a low glucose level, and potential positive gram stain and culture. Patients presumed to have bacterial meningitis should immediately receive broad-spectrum antibiotics to prevent clinical deterioration.

During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing

B. Decerebrate posturing

You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service: A. Hypoglycemia B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection Anything that can cause an irritating stimulus below the site of the spinal injury (T6 or higher) can lead to autonomic dysreflexia, which causes an exaggerated sympathetic reflex response and the parasympathetic system is unable to oppose it. This will lead to severe hypertension. The most common cause of AD is a bladder issue (full/distended bladder, urinary tract infection etc). Other common causes are due to a bowel issue like fecal impaction or skin break down (pressure injury/ulcer, cut, infection etc.).

A patient is scheduled to take 5 units of Humulin R and 10 units of NPH. What is the proper way of mixing these insulins? A. These insulins cannot be mixed, therefore, should be drawn up in different syringes. B. Draw-up the Humulin R insulin first and then the NPH insulin. C. Draw-up 2.5 units of NPH, then 10 units of Humulin R, and then finish drawing up 2.5 units of NPH. D. Draw-up the NPH insulin first and then the Humulin R insulin.

B. Draw-up the Humulin R insulin first and then the NPH insulin. Remember when drawing up regular and intermediate insulins...you draw-up clear (regular insulins) to cloudy (NPH intermediate). Remember the mnemonic R.N.

A patient in neurogenic shock is ordered intravenous fluids due to severe hypotension. During administration of the fluids the nurse will monitor the patient closely and immediately report? A. Increase in blood pressure B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) C. Urinary output of 300 mL in the past 5 hours D. Mean arterial pressure (MAP) 85 mmHg

B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) Remember that patients in neurogenic shock usually have a normal blood volume. If fluids are ordered to help increase the blood pressure, they should be used with extreme caution because fluid overload can occur. An increase in the CVP and PAWP would indicate this. These pressures show the filling pressure in the heart.

A physician orders a patient in thyroid storm to be started on Inderal. What in the patient's health history causes the nurse to question the doctor's order? A. History of mental illness B. History of asthma C. History of tachycardia D. History of cancer

B. History of asthma Patients with a history of asthma should not take Inderal (a beta blocker) because it can cause asthma exacerbation or bronchospasm. Therefore, the nurse should question this order.

You're patient is scheduled for an EEG (electroencephalogram). As the nurse you will: (Select all that apply) A. Keep the patient nothing by mouth. B. Hold seizure medications until after the test. C. Allow the patient to have coffee, milk, and juice only. D. Wash the patient's hair prior to the test. E. Administer a sedative prior to the test.

B. Hold seizure medications until after the test. D. Wash the patient's hair prior to the test. An EEG is a painless procedure that will assess the patient's brain activity (if a seizure occurs during the test this can allow the physician to determine what type of seizure it is). Therefore, the nurse would hold seizure medications (this can affect the test) and would NOT allow the patient to have caffeine like coffee or stimulant drugs (the patient can eat prior to the test just NO caffeine). The patient's hair should be cleaned prior to the test so the technician can apply the electrodes and get them to stick to the scalp easily. A sedative is not needed before this test.

A patient is scheduled to take a morning dose of Metformin. The patient is scheduled for surgery tomorrow. Which of the following nursing interventions are correct? A. Administer the medication as ordered. B. Hold the dose and notify the doctor for further orders. C. Administer the medication as ordered but hold the next day's dose. D. Check the patient's blood glucose prior to administering the medication.

B. Hold the dose and notify the doctor for further orders. Metformin (Glucophage) is held 48 hours prior to surgery (however a doctor's order is needed for this). Therefore, you should hold the dose and call the doctor for further orders.

The thyroid hormones, T3 and T4, play many roles in the human body. Which of the following functions are performed by T3 and T4? Note: Select all that apply A. Storing calories B. Increasing the Heart Rate C. Stimulating the Sympathetic Nervous System D. Decreasing the body's temperature E. Regulating TSH produced by the anterior pituitary gland

B. Increasing the Heart Rate C. Stimulating the Sympathetic Nervous System E. Regulating TSH produced by the anterior pituitary gland T3 and T4 burn calories (not store them) and increases body temperature (not decrease).

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming

B. Ineffective breathing pattern Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway. Option A: Continually assess motor function (as spinal shock or edema resolves) by requesting the patient to perform certain actions such as shrug shoulders, spread fingers, squeeze, release examiner's hands. Evaluates status of individual situation (motor-sensory impairment may be mixed or not clear) for a specific level of injury, affecting type and choice of interventions. Option C: Assess and document sensory function or deficit (by means of touch, pinprick, hot or cold, etc.), progressing from an area of deficit to a neurologically intact area. Changes may not occur during acute phase, but as spinal shock resolves, changes should be documented by dermatome charts or anatomical landmarks ("2 in above nipple line"). Provide tactile stimulation, touching the patient in intact sensory areas (shoulders, face, head). Option D: The other options may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but don't take precedence over a diagnosis of ineffective breathing pattern. Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance and ability. Prevents fatigue, allowing opportunity for maximal efforts and participation by patient.

A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will? A. Assess the patient for a rash B. Initiate seizure precautions C. Hold the next dose of Phenytoin D. Continue to monitor the patient

B. Initiate seizure precautions A normal Phenytoin level is 10 to 20 mcg/mL. The patient's level is low; therefore, the patient is at risk for seizures. The nurse should initiate seizure precautions. Remember a patient being under medicated is a trigger for developing a seizure.

Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A. Congenital anatomic abnormality of the meninges. B. Lack of acquired resistance to the various etiologic organisms. C. Occlusion or narrowing of the CSF pathway. D. Natural affinity of the CNS to certain pathogens.

B. Lack of acquired resistance to the various etiologic organisms. Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility. Meningitis can be caused by infectious and non-infectious processes (autoimmune disorders, cancer/paraneoplastic syndromes, drug reactions). The infectious etiologic agents of meningitis include bacteria, viruses, fungi, and less commonly parasites. Option A: The most common viral agents of meningitis are non-polio enteroviruses (group b coxsackievirus and echovirus). Other viral causes: mumps, Parechovirus, Herpesviruses (including Epstein Barr virus, Herpes simplex virus, and Varicella-zoster virus), measles, influenza, and arboviruses (West Nile, La Crosse, Powassan, Jamestown Canyon). Option C: Organisms can enter the cerebrospinal fluid (CSF) via neighboring anatomic structures (otitis media, sinusitis), foreign objects (medical devices, penetrating trauma), or during operative procedures. Viruses can penetrate the central nervous system (CNS) via retrograde transmission along neuronal pathways or by hematogenous seeding. Option D: Bacteria colonize the nasopharynx and enter the bloodstream after mucosal invasion. Upon making their way to the subarachnoid space, the bacteria cross the blood-brain barrier, causing a direct inflammatory and immune-mediated reaction.

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine.

Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working? A. Decreased CVP (central venous pressure) B. Mean arterial pressure (MAP) 90 mmHg C. Serum lactate 6 mmol/L D. Blood pH 7.20

B. Mean arterial pressure (MAP) 90 mmHg A MAP of 85-90 mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction. Options A, C, and D would indicate tissue perfusion is decreased.

A patient was recently discharged home for treatment of hypothyroidism and was ordered to take Synthroid for treatment. The patient is re-admitted with signs and symptoms of the following: heart rate 42, blood pressure 70/56, blood glucose 55, and body temperature of 96.8 'F. The patient is very fatigued and drowsy. The family reports the patient has not been taking Synthroid since being discharged home from the hospital. Which of the following conditions is this patient most likely experiencing? A. Thryoid Storm B. Myxedema Coma C. Iodism D. Toxic Nodular Goiter

B. Myxedema Coma Myxedema Coma...The red flags in this question are the patient's signs/symptoms and the report from the family the patient hasn't been taking the prescribed Synthroid. The patient is showing signs and symptoms of extreme hypothyroidism known as Myxedema coma (which is life-threatening if not treated).

In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury? A. Flushed lower body B. Pale and cool lower extremities C. Low blood pressure D. Absent reflexes

B. Pale and cool lower extremities The lower extremities would be cool and pale due to vasconstriction caused by the exaggerated reflex response of the sympathetic nervous system from an irritating stimulus. The sympathetic reflex can NOT be unopposed by the parasympathetic nervous system due to the spinal injury, which is blocking the nerve impulse. The areas found ABOVE the site of injury would be flushed due to vasodilation from parasympathetic stimulation.

When is a patient most susceptible to hypoglycemic symptoms after the administration of insulin? A. Onset B. Peak C. Duration D. Duration & Peak

B. Peak

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities. B. Rigid extension and pronation of the arms and legs. C. Rigid pronation of all extremities. D. Flaccid paralysis of all extremities.

B. Rigid extension and pronation of the arms and legs. Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs. Synonymous terms for decerebrate posturing include abnormal extension, decerebrate rigidity, extensor posturing, or decerebrate response. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons.

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

B. Schedule intermittent catheterization every 2 to 4 hours. Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Begin bladder retraining per protocol when appropriate (fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, Credé's maneuver). Option A: Begin intermittent catheterization program when appropriate. Intermittent catheterization may be implemented to reduce complications usually associated with long-term use of indwelling catheters. A suprapubic catheter may also be inserted for long-term management. Option C: Indwelling catheters may predispose the client to infection and are removed as soon as possible. Keep the bladder deflated by means of indwelling catheter initially. Indwelling catheter is used during acute phase for prevention of urinary retention and for monitoring output. Option D: Crede's maneuver is not used on people with spinal cord injury. Timing and type of bladder program depend on type of injury (upper or lower neuron involvement). Note: Credé's maneuver should be used with caution because it may precipitate autonomic dysreflexia.

Which of the following abnormal electrolyte imbalances is EXPECTED with Addisonian Crisis? A. Potassium level of 3.2 B. Sodium level of 112 C. Blood glucose level of 120 D. Phosphate level of 1.2

B. Sodium level of 112 Remember with Addisonian Crisis the 3'H (hypoglycemia, hyponatremia, and hyperkalemia). The potassium and blood glucose levels are normal in this question. Phosphate levels are not significant in Addisonian Crisis. The sodium level is very low which represents hyponatremia. Normal sodium level is 135-145.

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. Absence of pain sensation in chest B. Spasticity C. Spontaneous respirations D. Urinary continence

B. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. Spinal shock is a result of severe spinal cord injury. It usually requires high-impact, direct trauma that leads to spinal cord injury and spinal shock. The initial encounter with a patient that has spinal shock is usually under a trauma scenario. Option A: The absence of pain sensation in the chest doesn't apply to spinal shock. With high cervical injuries, the diaphragmatic function will be compromised, and these patients will necessitate early tracheotomy since they will be ventilator dependent. Deep vein thrombosis is excessively high in these patients. Option C: Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. In spinal shock, there is a transient increase in blood pressure due to the release of catecholamines. This is followed by a state of hypotension, flaccid paralysis, urinary retention, and fecal incontinence. The symptoms of spinal shock may last a few hours to several days/weeks. Option D: The full spinal examination should include motor, sensory reflexes including bulbocavernosus reflex and anal wink reflex. Motor activity and strength decrease not only in the skeletal muscles but the motor activity of internal organs like bowel and bladder. This decrease leads to constipation and urinary retention.

A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock? A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension. B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. C. The patient's parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension. D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.

B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. The sympathetic nervous system (which is a division of the autonomic nervous system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there's a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.

A patient taking IV Synthroid starts to complain of feeling hot and chest pain. On assessment, you find that the heart rate is 125 bpm and blood pressure is 200/103. You immediately notify the physician of the patient's condition and receive orders for lab work. Based on the patient's signs and symptoms, what is the MOST important lab result at this time to determine the cause of the patient's symptoms? A. Potassium level B. Thyroid levels C. Calcium level D. Sodium level

B. Thyroid levels The patient is receiving IV Synthroid. Therefore, the nurse must monitor for toxicity which would present with elevated THYROID levels. Remember Synthroid is a thyroid replacement medication. This would present with the patient complaining of feeling hot, chest pain, tachycardia, and hypertension (similar signs and symptoms of HYPERthyroidism).

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

B. To immobilize the cervical spine. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished. There are several uses for GWT, including the treatment of cervical spine fractures, patient positioning inside the operating room, and skeletal traction during spinal deformity surgery. Aside from GWT, different apparatuses have been utilized for skeletal traction, including Crutchfield's caliper, Cone's caliper, Blackburn's caliper, and halo traction. Option A: GWT have become popular in the United States due to their ease of use, and effectiveness in reducing cervical dislocations in a traumatic setting. Several advantages over previous traction devices include the lack of skin incisions, antiseptic instead of aseptic technique, and the lack of drill holes. Option C: Proper bladder and bowel care (ie, preventing fecal impaction, bladder distention) are mainstays in preventing episodes of autonomic dysreflexia. Regulation of the bladder routine via indwelling Foley catheter or intermittent catheterization and regular urologic follow-up is highly recommended for autonomic dysreflexia prevention. Option D: GWT has many advantages that have led to their increased popularity and usage. These include the relative ease of use, sterile technique, lack of incisions, reduced screw pullout, and elimination of burr holes.

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier

B. Vasodilation of cerebral vessels D. Leaking proteins into the brain barrier These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).

The nurse is assessing the breathing pattern of a patient with a head injury who has a change in level of consciousness. Which pathophysiologic event causes an irregular respiratory pattern as level of consciousness decreases? Pressure on the meninges Reflexive motor responses Loss of the oculocephalic reflex Brainstem responses to changes in PaCO2

Brainstem responses to changes in PaCO2 Rationale: When there is damage to the reticular activating system or cerebral hemispheres, neural control of these centers is lost, and lower brainstem centers regulate breathing patterns by responding only to changes in PaCO2, resulting in irregular respiratory patterns. Blood in the ventricles or subarachnoid space irritates the meninges and brain tissue, causing an inflammatory reaction and impairing absorption and circulation of cerebrospinal fluid. Reflexive motor responses may occur as brain function declines. Loss of oculocephalic reflexes indicates a deterioration in brainstem functioning

During the initial assessment of patient with a probable spinal cord injury, the nurse performs a digital rectal examination. What is the best rationale for this examination? A) Part of routine admission physical B) Checks for fecal impaction C) Assesses for sensation or movement D) Preliminary for rectal medications

C) Assesses for sensation or movement

A nurse is caring for a patient with a traumatic brain injury who is paralyzed. The nurse must decide how best to meet the nutritional needs of this patient. What intervention is best to support the nutritional needs of the patient? A) Replace 140% of the patients resting energy expenditure via parenteral nutrition. B) Meet metabolic demands of the patient within 8 to 10 days of the injury. C) Collaborate with a nutrition support team to meet the patients nutritional needs. D) Maintain the patients blood sugar level at 300 mg/dL.

C) Collaborate with a nutrition support team to meet the patients nutritional needs.

Following a lumbar puncture for CSF analysis, a patient with elevated intracranial pressure develops a headache, nuchal rigidity, fever, and difficulty voiding. What intervention should the nurse expect? A) Administration of IV fluids B) Administration of antibiotic C) Injection of blood into the dura D) Cardiopulmonary resuscitation

C) Injection of blood into the dura

About 6 weeks after a concussion injury, the patient is complaining of headaches, decreased attention span, and short-term memory impairment. The patient expresses extreme frustration and anxiety. What is the best nursing intervention? A) Obtain an order for a repeat computed tomography (CT) scan B) Admit the patient for a complete neurologic evaluation C) Provide emotional support and explanations D) Refer to psychiatry for evaluation and treatment

C) Provide emotional support and explanations

The nurse is conducting tests of a patients cerebellar synchronization of movement with balance. What result of the finger-to-nose test would indicate cerebellar dysfunction? A) The patient has trouble understanding the nurses instructions. B) The patient cannot reach his or her nose due to restricted range of motion in the elbow. C) The patient overshoots when trying to touch his or her nose. D) The patient cannot touch his or her nose due to a trembling hand.

C) The patient overshoots when trying to touch his or her nose.

The nurse is evaluating the cognitive function of a patient with impaired neurologic functioning after an acute brain injury. What is the best nursing approach for evaluation of orientation to person, place, and time? A) Ask exactly the same questions each time. B) Ask if the patient knows where he is. C) Vary the questions slightly each time. D) Ask the family to corroborate information.

C) Vary the questions slightly each time.

A patient is in critical care recovering from a spinal cord injury. As part of shift report, the nurse is told that the patients injury is between C1 and C4 and involves the entire cord. The patient is on a mechanical ventilator. What is the best nursing action to provide for patient safety? A) Be sure all side rails are up at all times. B) Keep the bed in low position when unattended. C) Verify that a functioning bag-mask resuscitator is at the bedside. D) Place the call light in the patients hand.

C) Verify that a functioning bag-mask resuscitator is at the bedside.

The patient's blood pressure is 130/88. What is the patient's mean arterial pressure (MAP)? A. 42 B. 74 C. 102 D. 88

C. 102 MAP is calculated by taking the DBP (88) and multiplying it by 2. This equals 176. Then take this number and add the SBP (130). This equals 306. Then take this number and divide by 3, which equal 102.

A patient is scheduled to take 7 units of Humulin R at 0830. You administer Humulin R at 0900 in the right thigh. When do you expect this medication to peak? A. 1300 B. 0930 C. 1100 D. 1700

C. 1100 Humulin-R is a SHORT-ACTING insulin which has a PEAK time of 2 hours. If you gave the medication at 0900...it would peak at 1100.

A patient is receiving treatment for myxedema coma with IV Synthroid. Which of the following findings would require nursing intervention for this patient? A. Blood glucose 75 B. Sodium level of 138 C. A physician's order for Fentanyl 0.25 mcg every 2 hours for pain D. Temperature 98.9 'F

C. A physician's order for Fentanyl 0.25 mcg every 2 hours for pain The other options are normal readings...however, patients with myxedema coma should not receive sedatives or narcotics (Fentanyl is a narcotic) because these patients are very sensitive to them. Therefore, the nurse should intervene and question the doctor's order.

Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action? A. Perform a bladder scan B. Perform a rectal digital examination C. Assess the patient's blood pressure D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.

C. Assess the patient's blood pressure This is the nurse's NEXT action. The patient is at risk for developing autonomic dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk). If a patient with this type of injury states they have a headache, the nurse should NEXT assess the patient's blood pressure. If it is elevated, the nurse would take measures to check the bladder (a bladder issue is the most common cause of AD), bowel, and skin for breakdown.

A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? A. Adenosine B. Warfarin C. Atropine D. Norepinephrine

C. Atropine Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn't working the way it should, it can NOT oppose the parasympathetic system....which will take over and lead to bradycardia.

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

C. BP 200/60, HR 50, RR 8 These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.

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

C. By performing a jaw thrust maneuver. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway. Option A: Assess respiratory function by asking the patient to take a deep breath. Note presence or absence of spontaneous effort and quality of respirations (labored, using accessory muscles). C-1 to C-3 injuries result in complete loss of respiratory function. Injuries at C-4 or C-5 can lead to variable loss of respiratory function, depending on phrenic nerve involvement and diaphragmatic function, but generally cause decreased vital capacity and inspiratory effort. Option B: If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. Option D: The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury. Tilting the head or otherwise moving the neck is contraindicated in a patient with a possible cervical spine injury, but maintaining an airway and ventilation is a greater priority. In the setting of a possible cervical spine injury, the jaw-thrust maneuver, in which the neck is held in a neutral position, is preferred over the head tilt-chin lift maneuver.

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

C. Epidural hematoma An epidural hematoma occurs when blood collects between the skull and the dura mater. An epidural hematoma (EDH) is an extra-axial collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull. It is confined by the lateral sutures (especially the coronal sutures) where the dura inserts. It is a life-threatening condition, which may require immediate intervention and can be associated with significant morbidity and mortality if left untreated. Rapid diagnosis and evacuation are important for a good outcome. Option A: In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. A subdural hematoma forms because of an accumulation of blood under the dura mater, one of the protective layers to the brain tissue under the calvarium. The understanding of subdural hematoma relies on the knowledge of neuroanatomical sheets covering the brain. Option B: In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. Subarachnoid hemorrhage is defined as blood between the arachnoid membrane and the pia membrane. Several factors compromise this syndrome. Most subarachnoid hemorrhages are traumatic in nature. Aneurysmal subarachnoid hemorrhage compromises a small portion of this patient population, but nevertheless is the most worrisome type of subarachnoid hemorrhage. Option D: A contusion is a bruise on the brain's surface. Contusions can progress and expand, and in many cases, other hemorrhagic contusions are present. Brain contusions have been attributed to bleeding from the continuous flow of injured microvessels during the initial traumatic episode. Hemorrhagic contusions overlie brain parenchyma with loss of function.

Which of the following statements are CORRECT about Grave's Disease? A. Grave's Disease is caused by independently functioning nodular goiters producing excessive amounts of T3 and T4. B. Grave's Disease is a complication of untreated hypothyroidism. C. Grave's Disease is caused by an autoimmune condition where the body produces an antibody called TSI (which acts like TSH on the body). D. Grave's Disease patients do not present with protruding eyes or a goiter, as in Toxic Nodular Goiter (TNG).

C. Grave's Disease is caused by an autoimmune condition where the body produces an antibody called TSI (which acts like TSH on the body).

___________ is an autoimmune disorder where the body attacks the thyroid gland that causes it to stop releasing T3 and T4. The patient is likely to have the typical signs/symptoms of hypothyroidism, however, they may present with what other sign as well? A. Myxedema coma; joint pain B. Thyroid storm; memory loss C. Hashimoto's Thyroiditis; goiter D. Toxic nodular goiter (TNG); goiter

C. Hashimoto's Thyroiditis; goiter

An 8-year-old child, who is not responding to anti-seizure medications, is prescribed to start a ketogenic diet. This diet will include: A. High carbohydrates and high fat B. Low fat, high salt, and high carbohydrates C. High fat and low carbohydrates D. High glucose, high fat, and low carbohydrates

C. High fat and low carbohydrates This is a type of diet used in the pediatric population with epilepsy whose seizures cannot be controlled by medication. It is a high fat and low carb diet.

Which of the following below is NOT a sign or symptom of Addisonian Crisis? A. Low blood pressure B. Severe pain in the stomach, legs, and lower back C. Hypokalemia D. Hyponatremia

C. Hypokalemia Remember the 5'S & 3'H: Super low blood pressure (nothing will bring it up), Sudden pain in stomach, back, and legs, Syncope (going unconscious) , Shock, Severe vomiting, diarrhea and headache & Hyponatremia, Hyperkalemia, Hypoglycemia

All of the following are treatments for myxedema coma EXCEPT? A. Corticosteroids B. IV glucose C. Hypotonic IV solutions D. IV Synthroid

C. Hypotonic IV solutions HYPERtonic or normal saline solutions are used to treat myxedema coma due to the present of hyponatremia....not HYPOtonic solutions

A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35

C. ICP 24 mmHg A ventriculostomy is a catheter inserted in the area of the lateral ventricle to assess ICP. It will help drain CSF during increase pressure readings and measure ICP. The nurse must monitor for ICP levels greater than 20 mmHg and report it to the doctor.

Keeping the previous question in mind, the patient is now experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should? A. Continue to monitor the patient B. Suction the patient C. Initiate the emergency response system D. Restrain the patient to prevent further injury

C. Initiate the emergency response system Tonic-clonic seizures should last about 1-3 minutes. If the seizure lasts MORE than 5 minutes, the patient needs medical treatment FAST to stop the seizure....this is known as status epilepticus.

Which of the following are NOT a cause of myxedema coma? A. Illness B. Sedatives C. Iodine Toxicity D. Thyroidectomy

C. Iodine Toxicity Iodine toxicity can cause HYPERthyroidism issues not HYPOthyroidism issues.

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child. B. Allowing the child to play in the bathtub. C. Keeping extraneous noise to a minimum. D. Performing treatments quickly.

C. Keeping extraneous noise to a minimum. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. Maintain a quiet environment and keep the lights dim. Prevents stimulation that can cause or precipitate an episode of convulsion. Option A: There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. Stay with infant/child and sit nearand speak in a low voice. Provides limited stimulation to the infant/child during an acute stage of disease. Option B: The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Provide a quiet environment free from bright lighting, minimize gentle handling and care of the infant/child, allow for rest periods between care or procedures, restrict visiting if irritable. Option D: Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

A patient with diabetes asks you about what type of exercise they should perform throughout the week. The best response is: A. Lifting weights B. Sprinting C. Swimming D. Jumping

C. Swimming Aerobic exercise is the best and swimming is the only option that is an aerobic exercise.

You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority? A. Keeping the head of the bed greater than 45 degrees at all times. B. Repositioning the patient every thirty minutes. C. Keeping the patient's spine immobilized. D. Avoiding log-rolling the patient during transport.

C. Keeping the patient's spine immobilized. It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient's spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.

Which of the following insulins has no peak but a duration of 24 hours? A. NPH B. Novolog C. Lantus D. Humulin N

C. Lantus Lantus is the only option here that is a LONG-ACTING insulin which has NO peak and a 24 hour duration.

Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to? A. Continue assisting the patient to the restroom and let them sit down. B. Initiate the emergency response system. C. Lay the patient down on their side with a pillow underneath the head. D. Assess the patient's medication history.

C. Lay the patient down on their side with a pillow underneath the head. The patient is reporting signs and symptoms of an aura (this is a warning sign before a seizure event). Lay the patient down on their side with a pillow underneath the head and remove any restrictive clothing. Also, time the seizure. If the seizure lasts more than 5 minutes or if the patient starts to have seizures back-to-back activate the emergency response system.

A patient is being treated for Grave's Disease. They have a health history of type 1 diabetes, breast cancer, eczema, and hypertension. The physician orders Inderal. What important information will you include in their discharge teaching about this medication? A. Importance of taking the medication only as needed for symptoms. B. Avoid aged cheeses and wines while taking this medication. C. Monitor blood glucose levels closely because this medication can mask the signs and symptoms of hypoglycemia. D. Monitor heart rate regularly because this medication will increase the heart rate.

C. Monitor blood glucose levels closely because this medication can mask the signs and symptoms of hypoglycemia. Inderal is a beta-blocker which can cause masking of hypoglycemia in diabetic patients. Therefore, the patient must monitor blood glucose levels closely while taking this medication to treat Grave's Disease.

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

C. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation. Option A: Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Autonomic dysreflexia is a condition that emerges after a spinal cord injury, usually when the injury has occurred above the T6 level. The higher the level of the spinal cord injury, the greater the risk with up to 90% of patients with cervical spinal or high-thoracic spinal cord injury being susceptible. Option B: Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Hemorrhagic shock is due to the depletion of intravascular volume through blood loss to the point of being unable to match the tissues demand for oxygen. As a result, mitochondria are no longer able to sustain aerobic metabolism for the production of oxygen and switch to the less efficient anaerobic metabolism to meet the cellular demand for adenosine triphosphate. Option D: Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility. Pulmonary embolism (PE) occurs when there is a disruption to the flow of blood in the pulmonary artery or its branches by a thrombus that originated somewhere else.

You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST? A. Reassess the patient's blood pressure. B. Check the patient's blood glucose. C. Position the patient at 90 degrees and lower the legs. D. Provide cooling blankets for the patient.

C. Position the patient at 90 degrees and lower the legs. Based on the patient findings and how the patient has a spinal cord injury at T6, they are experiencing autonomic dysreflexia. Patients with this condition may have a blood pressure that is 20-40 mmHg higher than their baseline and may experience bradycardia (heart rate less than 60). The FIRST action the nurse should take when AD is suspected is to position the patient at 90 degree (high Fowler's) and lower the legs. This will allow gravity to cause the blood to pool in the lower extremities and help decrease the blood pressure. Then the nurse should try to find the cause of the autonomic dysreflexia, which could be a full bladder, impacted bowel, or skin break down.

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

C. Remove extra blankets and give the patient a cool bath It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).

A patient is being discharged home for treatment of hypothyroidism. Which medication is most commonly prescribed for this condition? A. Tapazole B. PTU (Propylthiouracil) C. Synthroid D. Inderal

C. Synthroid Synthroid is the only medication listed that treats hypothyroidism. All the other medications are used for hyperthyroidism.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure. B. To prevent acute tubular necrosis. C. To promote osmotic diuresis to decrease ICP. D. To draw water into the vascular system to increase blood pressure.

C. To promote osmotic diuresis to decrease ICP. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern. The mannitol causes the cells in the brain to dehydrate mildly. The water inside the brain cells (intracellular water) leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream. Once in the bloodstream, the extra water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys filter the mannitol into the urine. Option A: Mannitol may be used to reduce intraocular pressure when given intravenously. The mannitol is a new solute in the intravascular space, which increases the tonicity of the blood plasma. The increased tonicity of the blood plasma draws water out of the vitreous humor of the eye and into the intravascular space. Once in the intravascular space, the mannitol and associate water are excreted by the kidney. The decreased water of the vitreous humor lowers the intraocular pressure. Option B: Much like mannitol given for oliguria of acute renal failure, mannitol can be given to increase the excretion of toxic materials, substances, and drugs. The kidneys excrete mannitol. The mannitol is poorly reabsorbed once excreted and thus draws extra water with it into the renal collecting ducts. The extra water in the renal collecting ducts can help increase the excretion of water-soluble toxic materials, substances, and drugs. Option D: Intradialytic hypotension and dialysis disequilibrium symptoms are common in hemodialysis patients. This is due to a drop in intradialytic osmolality. Mannitol can be used to prevent intradialytic hypotension by raising serum osmolality.

A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? A. phenytoin (Dilantin) B. mannitol (Osmitrol) C. lidocaine (Xylocaine) D. furosemide (Lasix)

C. lidocaine (Xylocaine) Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Lidocaine use, both intravenous (IV) and laryngotracheal (LT), has been reported to blunt the ICP elevations during intubation. Though one would assume that the ICP mediated effects of lidocaine stem from its local anesthetic effect, there are other proposed mechanisms of ICP reduction via the IV route. Lidocaine injected IV has been shown in models to induce cerebral vasoconstriction leading to a decrease in cerebral blood volume and thus ICP. Furthermore, IV lidocaine leads to sodium channel inhibition and thus a reduction in cerebral activity and metabolic demands, as well as excitotoxicity, leading to a potential ICP reduction effect. Option A: Phenytoin doesn't reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn't administered endotracheally. Phenytoin is a hydantoin derivative, a first-generation anticonvulsant drug that is effective in the treatment of generalized tonic-clonic seizures, complex partial seizures, and status epilepticus without significantly impairing neurological function. Option B: Mannitol may be used for the reduction of intracranial pressure. In this indication, mannitol administration is intravenous. Mannitol then constitutes a new solute in the plasma, which increases the tonicity of the plasma. Since mannitol cannot cross the intact blood-brain barrier, the increased tonicity from the mannitol draws water out of the brain parenchyma and into the intravascular space. The water then travels with the mannitol to the kidneys, where it gets excreted in the urine. Option D: Although furosemide may be given to reduce ICP, they're administered parenterally, not endotracheally. Furosemide inhibits tubular reabsorption of sodium and chloride in the proximal and distal tubules, as well as in the thick ascending loop of Henle by inhibiting sodium-chloride cotransport system resulting in excessive excretion of water along with sodium, chloride, magnesium, and calcium.

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

C. methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance. Methylprednisolone and its derivatives, methylprednisolone acetate succinate, and methylprednisolone sodium, are intermediate-acting, synthetic glucocorticoids used mainly as anti-inflammatory or immunosuppressive agents. Methylprednisolone is five times more potent in its anti-inflammatory properties relative to hydrocortisone (cortisol), with minimal mineralocorticoid activities compared to the latter. Option A: Acetazolamide is a diuretic and carbonic anhydrase inhibitor medication that is used to treat several illnesses. Acetazolamide is a classic treatment option for glaucoma as it causes a reduction in the aqueous humor. As well, it is useful for the treatment of altitude sickness, because of its underlying mechanism of action. The medication works to excrete bicarbonate. Option B: The Food and Drug Administration (FDA) has approved the use of furosemide in the treatment of conditions with volume overload and edema secondary to congestive heart failure exacerbation, liver failure, or renal failure including the nephrotic syndrome. Option D: The main therapeutic effect of sodium bicarbonate administration is in increasing plasma bicarbonate levels, which are known to buffer excess hydrogen ion concentration, thereby raising solution pH to combat clinical manifestations of acidosis.

Lugol's solution helps block ________ of thyroid hormones in thyroid storm. Which of the following are a common side effect of this medication? A. the removal; tophi B. excretion; swollen lymph nodes C. release/ synthesis; taste changes D. movement; hypocalcemia

C. release/ synthesis; taste changes

A comatose patient with a traumatic brain injury is being tested for cranial nerve damage. The nurse passes a wisp of cotton over the lower conjunctiva of each eye. The patients lower eyelid in each eye twitches when the cotton makes contact with the cornea. The nurse recognizes that this result indicates which of the following? A) The trigeminal nerve is functioning properly but the facial nerve is not B) The facial nerve is functioning properly but the trigeminal nerve is not C) Neither the trigeminal nerve nor the facial nerve is functioning properly D) Both the trigeminal and the facial nerves are functioning properly

D) Both the trigeminal and the facial nerves are functioning properly

A patient is suspected of having injury to his carotid artery following trauma to his neck after engaging in a fight during a hockey game. Which diagnostic test would be most effective in investigating this injury? A) Computed tomography (CT) B) Magnetic resonance imaging (MRI) C) Electroencephalogram (EEG) D) Cerebral angiography

D) Cerebral angiography

A patient with a traumatic brain injury is at high risk for a secondary brain injury. What is the best nursing explanation of a secondary brain injury? A) Result of a repeated assault incident B) From a penetrating gunshot wound C) Trauma inflicted by another person D) Cerebral edema and ischemia

D) Cerebral edema and ischemia

A patient with a skull fracture has a positive halo sign. What does this sign indicate? A) Fracture of the anterior fossa B) Presence of a basilar skull fracture C) Impingement of cranial nerves D) Cerebrospinal fluid leak

D) Cerebrospinal fluid leak

The patient has a spinal cord lesion at T1-T2. About an hour after being turned, the patient experiences a sudden throbbing headache accompanied by extreme blood pressure elevation and profound bradycardia. The patient has a very flushed face. What is the nursing priority? A) Administer pain medication immediately. B) Give intravenous beta-antagonist medication. C) Turn on a fan. D) Check Foley catheter for twisting or kinks.

D) Check Foley catheter for twisting or kinks.

A patient with a spinal cord lesion at C6-C7 has developed pneumonia and is placed on kinetic therapy producing constant lateral rotation to 40 degrees bilaterally. What is a nursing priority of care for this patient relative to the kinetic therapy? A) Measure intake and output hourly. B) Provide nutrition with adequate protein. C) Auscultate bowel sounds every 4 hours. D) Inspect skin surfaces every 4 hours.

D) Inspect skin surfaces every 4 hours.

A patient is recovering from a lumbar spine injury and requires an immobilization device for this region. Which device would be most appropriate for this patient? A) Halo vest B) Aspen collar C) Minerva brace D) Jewett brace

D) Jewett brace

While assessing motor function, the nurse applies pressure to a toenail. What patient response is most normal? A) Extension of both feet B) Flexion of knee and ankle C) Extension of one or both arms D) Kicking the nurses hand away

D) Kicking the nurses hand away

A nurse is monitoring a patient with spinal cord injury for respiratory complications. Which of the following findings would indicate that the patient should be intubated? A) Respiratory rate of 20 breaths/minute B) Vital capacity of 30 mL/kg C) PaO2 of 90 mm Hg D) PaCO2 of 60 mm Hg

D) PaCO2 of 60 mm Hg

A neurologist who is testing a patient for neurological deficits has her close her eyes and then hands her a stethoscope. He asks her to identify the object by touch, but she cannot do so. The nurse, observing this result, should suspect possible damage to which part of the brain? A) Cerebellum B) Temporal lobe C) Frontal lobe D) Parietal lobe

D) Parietal lobe

A patient suffered damage to cranial nerve VIII in a jet ski accident. What symptom or symptoms should the nurse tell the patient to expect? Select all that apply. A) Loss of the sense of smell B) Partial blindness in one eye C) Paralysis of face muscles on one side of the face D) Tinnitus E) Dizziness F) Inhibited ability to move the tongue

D) Tinnitus E) Dizziness CN VIII injury pathology can result from direct trauma, congenital malformations, tumor formation, infection, and vascular injury. Presenting symptoms include vertigo (DIZZINESS), nystagmus, tinnitus, and sensorineural hearing loss. Tinnitus is ringing in the ears. It also can sound like roaring, clicking, hissing, or buzzing. It may be soft or loud, high pitched or low pitched. Also, the involvement of the facial nerve, due to its proximity, should not be excluded during evaluation.

While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips

D. Flexion of the hips Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP.

A patient is admitted with thyroid storm. Which sign and symptoms are NOT present with this condition-SELECT ALL THAT APPLY? A. Temperature of 104.9'F B. Heart rate of 125 bpm C. Respirations of 42 D. Heart rate of 20 bpm E. Intolerance to cold F. Restless

D. Heart rate of 20 bpm E. Intolerance to cold Bradycardia (heart rate of 20 bpm) and intolerance to cold are NOT signs and symptoms of thyroid storm. All the other options are very typical signs and symptoms of thyroid storm.

A patient reports they do not eat enough iodine in their diet. What condition are they most susceptible to? A. Pheochromocytoma B. Hyperthyroidism C. Thyroid Storm D. Hypothyroidism

D. Hypothyroidism Hypothyroidism...Iodine helps make T3 and T4....if a person does not consume enough iodine they are at risk for developing HYPOTHYROIDISM.

A patient is recovering from myxedema coma and will be discharged tomorrow. What will you include in their discharge teaching? A. Avoiding green leafy vegetables. B. Importance of taking Tapazole exactly as prescribed at the same time every day. C. Limiting foods with Iodine such as kelp, dairy, and eggs. D. Importance of taking Synthroid in the morning without any food.

D. Importance of taking Synthroid in the morning without any food. Synthroid should be taken in the morning without food so absorption is not affected. All the other options are incorrect discharge education for patients suffering from myxedema coma.

The role of cortisol in the body includes: A. Decreasing the blood sugar and inhibiting fat and carb production B. Synthesizing proteins and increasing carb excretion C. Elevating the blood pressure and maintaining ADH (anti-diuretic hormone) D. Increasing blood glucose levels, and breaking down fats, proteins, and carbs

D. Increasing blood glucose levels, and breaking down fats, proteins, and carbs

The nurse is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. The nurse makes it priority to? A. Avoid using lubricants B. Stimulate the bowel with rectal manipulation C. Slowly administer a saline solution prior to assessment D. Instill an anesthetic jelly prior to assessment

D. Instill an anesthetic jelly prior to assessment To avoid increasing autonomic dysreflexia symptoms by increasing the sympathetic reflex due to an irritating stimulus, the nurse should instill an anesthetic jelly before assessing the rectum for hardened stool. This is also important prior to catheterization to check the bladder for urine.

Hyperglycemic Hyperosmolar Nonketotic Syndrome would have all of the following signs and symptoms EXCEPT? A. Dry mucous membranes B. Polyuria C. Blood glucose >600 mg/dL D. Kussmaul breathing

D. Kussmaul breathing Kussmaul breathing is found in DKA due to the compensatory mechanism of the respiratory system. Remember that in DKA there are excessive ketones (none are present in HHNS) which are acids and this causes metabolic acidosis. Therefore, the respiratory system tries to "blow off" extra acid (carbon dioxide) to try to make the blood more alkalotic.

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

D. Limiting bladder catheterization to once every 12 hours. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every four (4) to six (6) hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Option A: Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Establish a regular daily bowel program (digital stimulation, prune juice, warm beverage, and use of stool softeners and suppositories at set intervals. Determine usual time and routine of postinjury evacuations. Option B: Massage and lubricate skin with bland lotion or oil. Protect pressure points by use of heel or elbow pads, lamb's wool, foam padding, egg-crate mattress. Use skin hardening agents (tincture of benzoin, karaya, Sween cream). Enhances circulation and protects skin surfaces, reducing risk of ulceration. Tetraplegic and paraplegic patients require lifelong protection from decubitus formation, which can cause extensive tissue necrosis and sepsis. Keep bed clothes dry and free of wrinkles, crumbs. Reduces or prevents skin irritation. Option C: Elevate lower extremities at intervals when in chair, or raise foot of bed when permitted in individual situations. Assess for edema of feet and ankles. Loss of vascular tone and "muscle action" results in pooling of blood and venous stasis in the lower abdomen and lower extremities, with increased risk of hypotension and thrombus formation.

Problems with memory and learning would relate to which of the following lobes? A. Frontal B. Occipital C. Parietal D. Temporal

D. Temporal The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The hippocampus is responsible for creating declarative memories-those that can be consciously thought of and verbalized. Declarative memory can be episodic and semantic. Episodic memory is the ability to remember a specific occasion in the past in its specific time and place. Meanwhile, semantic memory is the ability to recall general facts about the world. Option A: The frontal lobe primarily functions to regulate thinking, planning, and judgment. It is the largest lobe, located in front of the cerebral hemispheres, and has significant functions for our body, and these are prospective memory, a type of memory that involves remembering the plans that you made, from a simple daily plan to future lifelong plans; speech and language; personality; and movement control. Option B: The occipital lobe functions regulate vision. The role of this lobe is visual processing and interpretation. Typically based on the function and structure, the visual cortex is divided into five areas (v1-v5). The primary visual cortex (v1, BA 17) is the first area that receives the visual information from the thalamus, and its located around the calcarine sulcus. The visual cortex receives, processes, interprets the visual information, then this processed information is sent to the other regions of the brain to be further analyzed (example: inferior temporal lobe). Option C: The parietal lobe primarily functions with sensory function. The Superior parietal lobule contains the somatosensory association (BA 5, 7) cortex which is involved in higher-order functions like motor planning action. The Inferior parietal lobule (supramarginal gyrus BA 40, angular gyrus BA 39) has the Secondary somatosensory cortex (SII), which receives the somatosensory inputs from the thalamus and the contralateral SII, and they integrate those inputs with other major modalities (examples: visual inputs, auditory inputs) to form a higher-order complex functions.

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

D. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Cervical injuries lead to the same deficits as thoracic injuries and, also, may result in loss of function of the upper extremities leading to tetraplegia. Injuries above C5 may also cause respiratory compromise due to loss of innervation of the diaphragm. Option A: Aphasia is an impairment to comprehension or formulation of language caused by damage to the cortical center for language. It can be caused by many different brain diseases and disorders; however, cerebrovascular accident (CVA) is the most common reason for a person to develop aphasia. Option B: Hemiparesis is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing. Where the stroke occurred in the brain will determine the location of your weakness. Injury to the left side of the brain, which controls language and speaking, can result in right-sided weakness. Left-sided weakness results from injury to the right side of the brain, which controls nonverbal communication and certain behaviors. Option C: Paraplegia occurs as a result of injury to the thoracic cord and below. Paraplegia is a form of paralysis that mostly affects the movement of the lower body. People with paraplegia may be unable to voluntarily move their legs, feet, and sometimes their abdomen.

A client has a cervical spine injury at the level of C4. Which of the following conditions would the nurse anticipate during the acute phase? A. Absent corneal reflex. B. Decerebrate posturing. C. Movement of only the right or left half of the body. D. The need for mechanical ventilation.

D. The need for mechanical ventilation. The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. C3 to C4 contribute to breathing by controlling the muscles of the diaphragm. Patients with an injury in this area of the cervical spine can complain of difficulty breathing. Option A: Apart from the obvious physical complaints, neuropsychiatric symptoms noticeably vary out of proportion with the severity of the correspondent TBI. The patients who experience post-concussion syndrome may have somatic complaints like a headache, dizziness, cognitive impairment, and neuropsychiatric symptoms like anxiety, irritability, depression, and sleep disorders. Option B: Decerebrate posturing occurs with brain injuries, not spinal cord injuries. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons. Option C: TBI may result in a decrease in short and long-term global health (physical and behavioral) and put them at an elevated risk for disability, pain, and handicap (i.e., difficulty with a return to work, maintaining peer networks.) Rehabilitation therapies like physical therapy, occupational therapy, speech-language therapy, and assistive devices and technologies may help to strengthen patients to perform their activities of daily living.

True or False: A patient who is experiencing a tonic-clonic seizure is experiencing a focal (partial) seizure.

False A patient who is experiencing a tonic-clonic seizure is experiencing a GENERLAIZED seizure. This type of seizure affects both sides of the brain.

True or False: DKA and HHNS mainly occur in type 2 diabetics.

False DKA is most common in Type 1 diabetics, whereas HHNS is most common in Type 2 diabetics.

What is the GCS for a patient who only responds to your verbal commands, is confused and localizes to pain?

GCS 12 Responsive to verbal = 3 Confused = 4 Localizes pain = 5

What is the Glasgow Coma Score (GCS) for a patient who has spontaneous eye-opening, is oriented and obeys commands?

GCS 15 Spontaneous eye-opening = 4 Oriented = 5 Obeys commands = 6

What is the GCS for a patient who does not open his eyes, does not respond to verbal commands, and has no motor response?

GCS 3 Does not open eyes = 1 Does not respond to verbal = 1 No motor response= 1

A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient's labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next? Start the IV fluids and administer the insulin bolus and drip as ordered Hold the insulin and notify the doctor of the potassium level of 2.5 Hold IV fluids and administer insulin as ordered Recheck the glucose level

Hold the insulin and notify the doctor of the potassium level of 2.5 Remember when insulin is given it helps take potassium back into the cell which will cause potassium blood levels to fall. Insulin therapy is to be started only if the patient's potassium level is 3.3 or greater.

Which is a common complication found mainly in Type 2 diabetes? Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) Diabetic ketoacidosis

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

The nurse is assessing a patient with damage to the lower motor neurons. Which findings should the nurse expect to assess in this patient? (Select all that apply.) Loss of reflexes Increased muscle tone Decreased coordination Decreased muscle strength Muscle atrophy and fasciculations

Loss of reflexes Muscle atrophy and fasciculations Rationale: Damage to lower motor neurons causes decreased muscle tone, muscle atrophy, fasciculations, and loss of reflexes. Damage to upper motor neurons results in increased muscle tone, decreased muscle strength, decreased coordination, and hyperactive reflexes.

You are providing care to a patient experiencing diabetic ketoacidosis. The patient is on an insulin drip and their current glucose level is 300. In addition to this, the patient also has 5% Dextrose 0.45% NS infusing in the right antecubital vein. Which of the following patient signs/symptoms causes concern? Patient complains of thirst. Patient has a potassium level of 2.3 Patient's skin and mucous membranes are dry. Patient is nauseous.

Patient has a potassium level of 2.3 Insulin causes potassium to enter back into the cell; therefore removing it from the blood. If the potassium is already 2.3, the patient can bottom out their potassium level. Therefore, the patient needs potassium supplements which requires a doctor's order.

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. Performed active range of motion exercises every 4 hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

Position the client with the head of the bed elevated at intervals. The head of the clients bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.

A patient with a spinal cord injury is prescribed pantoprazole (Protonix). According to best practices, why is this medication prescribed for the patient? Prevents stress-related gastric ulcers. Encourages healing of gastric nerves. Promotes digestion of enteral feedings. Supports healthy bacteria in the gastrointestinal tract.

Prevents stress-related gastric ulcers. Rationale: A proton-pump inhibitor, such as pantoprazole (Protonix), is often prescribed to prevent stress-related gastric ulcers. This medication is not prescribed to encourage healing of gastric nerves, promote digestion of enteral feedings, or support healthy bacteria in the gastrointestinal tract

The clients diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained 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 millimeters in size and nonreactive to painful stimuli.

Purposeless movement in response to painful stimuli. Purposeless movement indicates that the clients cerebral edema is decreasing. The best motor responses purposeful movement, but purpose less movement indicates an improvement over the Decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

A patient is presenting to the emergency department with a seizure lasting longer than 30 minutes. The nurse is preparing diazepam (Valium) to be given intravenous (IV) push. Which of the following side effects is the priority for the nurse to assess for after administration? Vomiting Urinary retention Respiratory depression Tachycardia

Respiratory depression

A 70-year-old female was admitted for a traumatic brain injury from a fall earlier this morning. The initial neurologic exam reveals no deficit and client is ordered for an hourly neurologic assessment. What manifestation is an early sign of increased ICP? Unequal pupil size Decerebrate posturing Restlessness Bradycardia

Restlessness Early signs of increased ICP include restlessness, agitation and decreased LOC. Posturing, pupil changes and bradycardia are late ominous signs of increased ICP

The nurse assesses a depressed gag reflex in an unconscious patient. Which nursing diagnosis should the nurse use to guide this patient's care? Risk for Aspiration Ineffective Breathing Pattern Decreased Intracranial Adaptive Capacity Imbalanced Nutrition: Less Than Body Requirements

Risk for Aspiration Rationale: The unconscious patient with a depressed or absent gag and swallowing reflex is at high risk for aspiration since saliva and any fluids taken by mouth could not be swallowed normally. There is no information to support that the patient has an ineffective breathing pattern. There is no information to support that the patient has increased intracranial pressure, which would impair intracranial adaptive capacity. There is also not enough information to support that the patient has imbalanced nutrition. In the absence of a gag reflex, nutrition can be provided through other, nonoral routes.

A patient is admitted to the emergency department with a cervical SCI following an automobile crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The accident injured the patient's lungs. The nerves that control lung function have been injured. The patient is unable to breathe because of being unconscious. The ventilator is temporary to ensure the patient receives adequate oxygen until recovery.

The nerves that control lung function have been injured. Rationale: SCI at the C1-C4 level produces respiratory paralysis and the patient will be unable to breathe on his or her own, so a ventilator will be necessary to maintain respiratory function. The nerves controlling lung function have been injured. The patient does not have a lung injury. The use of a ventilator is not because the patient is unconscious. The use of a ventilator will not be temporary

An industrial nurse is conducting a class for manufacturing plant employees on methods to prevent back pain. What should the nurse include in this teaching? (Select all that apply.) Use large leg muscles to push when lifting. Bend from the waist to lift articles from the floor. Spread the feet apart to broaden the base of support. Work as closely as possible to the object to be moved. Always lift articles rather than rolling or pushing them.

Use large leg muscles to push when lifting. Spread the feet apart to broaden the base of support. Work as closely as possible to the object to be moved. Rationale: In teaching prevention of back injuries, the nurse would incorporate principles of proper body mechanics, which include using large leg muscles to push when lifting, spreading the feet apart to widen the base of support, and working close to the object being moved. Bending from the waist to lift objects and lifting instead of pushing or rolling objects can contribute to back injuries

When the nurse applies painful stimulus to the nailbeds of and unconscious patient, the patient responds with internal rotation, adduction and flexion of the arms. The nurse documents this finding as? a. Decorticate posturing b. Decerebrate posturing c. Flexion withdraw d. Localization of pain

a. Decorticate posturing

Use of Glasgow Coma Scale (GCS) provides a relatively objective assessment of Level of Consciousness (LOC). What are the Three functions assessed? a. Verbal response, eye opening, motor response b. Eye opening, motor response, sensation c. Verbal response, pupil reaction, motor response d. Pupil reaction, orientation, sensation

a. Verbal response, eye opening, motor response

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: a.) A positive Brudzinski's sign b.) A negative Kernig's sign c.) Absence of nuchal rigidity d.) A Glascow Coma Scale score of 15

a.) A positive Brudzinski's sign Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

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

a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Rationale: A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

A client who was in a motor vehicle accident a few days ago is now complaining of progressive weakness in his arms and upper body while the functioning of his lower limbs is unchanged. Which of the following might this client be experiencing? a.) Central cord syndrome b.) Whiplash syndrome c.) Anterior cord syndrome d.) Brown-Sequard syndrome

a.) Central cord syndrome Rationale: In central cord syndrome, motor and sensory function of the upper extremities is lost while the functioning of the lower extremities stays intact.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation (DIC)? a.) Hemorrhagic skin rash b.) Edema c.) Cyanosis d.) Dyspnea on exertion

a.) Hemorrhagic skin rash Rationale: DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? a.) Laceration of the middle meningeal artery b.) Rupture of the carotid artery c.) Thromboembolism from a carotid artery d.) Venous bleeding from the arachnoid space

a.) Laceration of the middle meningeal artery Rationale: Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. *Venous bleeding from the arachnoid space is usually observed with subdural hematoma

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be: a.) Normal saline. b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS

a.) Normal saline. Rationale: A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water. #2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema. #3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal

a.) Urine output increases Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracranial hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environment

a.) hypoventilation Rationale: Hypoventilation leads to vasodilation and increased intracranial pressure.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

The client with an old C6 spinal cord injury complains of suddenly being too warm, with nasal congestion and a very red face. What is your next assessment? a.) temperature b.) blood pressure c.) input and output for previous 8 hours d.) bowel for impaction

b.) blood pressure Rationale: This is autonomic dysreflexia and is usually associated with hypertension. Sit them up quickly and check blood pressure

A resident of a long term care facility fell during the previous shift and has a laceration to the occipital area that has been closed with steri-strips. Which signs or symptoms, if noted would warrant transferring the resident to an Emergency Department? a. 4 cm area of bright red, bloody drainage noted on the dressing b. Pupils that are equal, react to light and accommodate c. A weak pulse, shallow respirations, cool pale skin d. Complaints of a headache that is resolved with medication.

c. A weak pulse, shallow respirations, cool pale skin

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to a. obtain a specimen of the fluid and send for culture and sensitivity. b. take the patient's temperature to determine whether a fever is present. c. check the nasal drainage for glucose with a Dextrostik or Testape. d. have the patient to blow the nose and then check the nares for redness.

c. check the nasal drainage for glucose with a Dextrostik or Testape.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: a.) A cerebral lesion b.) A temporal lesion c.) An intact brainstem d.) Brain death

c.) An intact brainstem Rationale: Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? a.) An interval when the client's speech is garbled b.) An interval when the client is alert but can't recall recent events c.) An interval when the client is oriented but then becomes somnolent d.) An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

c.) An interval when the client is oriented but then becomes somnolent Rationale: A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry

c.) Brief neurologic assessment

A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care? a.) Provide good perineal care. b.) Pass nasogastric tube to decompress stomach. c.) Keep client warm with extra blankets. d) Stimulate the anal-rectal reflex.

c.) Keep client warm with extra blankets. Rationale: Poikilothermia is a loss of temperature control and is dangerous because the client's body temperature will depend upon the temperature in the environment. The client needs to be kept warm and monitored carefully to avoid thermal injuries from passive warming devices.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? a.) No precautions are required as long as antibiotics have been started b.) Maintain enteric precautions c.) Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics d.) Maintain neutropenic precautions

c.) Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics Rationale: A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

c.) Parietal Rationale: The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a.) Prevent respiratory alkalosis. b.) Lower arterial pH. c.) Promote carbon dioxide elimination. d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

c.) Promote carbon dioxide elimination. Rationale: The goal in treatment is to prevent acidemia by eliminating carbon dioxide.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a.) To reduce intraocular pressure b.) To prevent acute tubular necrosis c.) To promote osmotic diuresis to decrease ICP d.) To draw water into the vascular system to increase blood pressure

c.) To promote osmotic diuresis to decrease ICP Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be: a.) Acceleration b.) Penetrating c.) Rotational d.) Deceleration

d.) Deceleration or "Acceleration-Deceleration" Rationale: Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a.) Sternal rub b.) Pressure on the orbital rim c.) Squeezing the sternocleidomastoid muscle d.) Nail bed pressure

d.) Nail bed pressure Rationale: Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

Problems with memory and learning would relate to which of the following lobes? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

d.) Temporal Rationale: The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

For a patient with severe diabetic ketoacidosis, what treatment does the nurse expect to initiate? A) Large-volume intravenous crystalloid infusion B) Discontinuation of exogenous insulin C) Restriction of nutritional protein and fat D) Intravenous diuretic therapy

A) Large-volume intravenous crystalloid infusion

The nurse identifies the nursing diagnosis Risk for Injury as appropriate for a patient with type 2 diabetes mellitus because of peripheral neuropathy involving both feet. Which assessment would support this diagnosis? Loss of normal reflexes Normal sensation to touch "I can't feel my feet anymore." "I have been having chest pain."

"I can't feel my feet anymore." Rationale: The person with diabetes mellitus is at risk for injury from multiple factors. Neuropathies may alter sensation, gait, and muscle control. The impaired mobility, sensory deficits, and neurologic effects of complications of diabetes mellitus increase the risk of accidents, burns, falls, and trauma. The loss of normal reflexes may or may not increase the patient's risk for injuries. Having normal sensation would not increase the patient's risk for injuries. There are more appropriate diagnoses for the patient assessment of chest pain.

The nurse is teaching a patient with Addison's disease about the disease process. Which statement illustrates that the patient understands the teaching? "I wonder why I look suntanned all the time." "I know I should never alter my dose of medications." "I have purchased an emergency kit and keep it with me all the time." "I will be sure to stop taking my medications when I have an infection."

"I have purchased an emergency kit and keep it with me all the time." Rationale: Addison's disease is a disorder resulting from destruction or dysfunction of the adrenal cortex. The result is chronic deficiency of cortisol, aldosterone, and adrenal androgens, accompanied by skin pigmentation. Addisonian crisis is a life-threatening response to acute adrenal insufficiency. Triggers include surgery, acute systemic illness, trauma, or abrupt withdrawal of long-term corticosteroid therapy. Patients with Addison's disease must learn to provide lifelong self-care that includes taking medications. The patient will need to learn how to self-administer steroids and the importance of carrying at all times an emergency kit containing parenteral cortisone and a syringe/needle. Medications for this disorder are to be taken continuously. Abruptly discontinuing the medication is dangerous. In the event of an illness or other stressor, the amount of medication the patient needs will be altered by the healthcare provider

A prescription for levothyroxine sodium (Synthroid) is given to Mrs. Fox after being diagnosed with hypothyroidism. The patient voices understanding of how to take the medication when she states which of the following? A. "I must take the medication with meals." B. "I must take my pulse before taking the medication and report to the doctor a pulse greater than 100." C. "I will only need to take this medication until my thyroid blood levels are back to normal." D. "I can eat any food I choose as foods do not interfere with the medications."

"I must take my pulse before taking the medication and report to the doctor a pulse greater than 100." Rationale: The patient must take a pulse prior to taking the medication; a pulse >100 must be reported to the physician because it may indicate an excessive dose or response to the medication.

The nurse is providing discharge instructions to a patient with type 2 diabetes mellitus. Which patient statement indicates teaching about foot care at home has been successful? "I always buy my shoes as soon as the stores open." "I will walk barefooted as long as I am in the house." "I will check my feet for cuts and bruises every night." "If I get a blister, I will just put alcohol on it and bandage it."

"I will check my feet for cuts and bruises every night." Rationale: Visual inspection of the feet each day is important in preventing more serious complications. Shoes should be purchased later in the day when feet are at their largest. Footwear should be worn at all times. The patient should be instructed to never walk barefoot. Foot wounds should be treated by a healthcare professional.

Mr. Blew understands diabetic teaching implemented by the nurse when he states which of the following? A. "I will check my blood glucose each morning before breakfast." B. "If I follow my prescribed diet, I will not have to check my blood sugar." C. "If my blood glucose drops below 60, I can drink 4 ounces of fruit juice to raise it." D. "If my blood sugar is over 200, I can eat graham crackers to lower it."

"If my blood glucose drops below 60, I can drink 4 ounces of fruit juice to raise it." Rationale: Fast-acting carbohydrates, such as 4 ounces of fruit juice or 8 ounces of skim milk, may be administered to raise the blood glucose level.

The patient in ICU has an intraventricular monitoring device. The patient's family is very anxious about the device and asks whether this is dangerous. The BEST response by the nurse is which of the following: "Please don't worry, we will take very good care of your loved one." "This device is an accurate means of measuring the pressure within the brain. We can also withdraw samples of the cerebrospinal fluid." "The tube is placed in the brain to monitor pressure caused by fluid. There are risks, but the benefits support more effective treatments." "The catheter is placed in the space just above the skull bone and under the skin so there are very few risks. We will remove it as soon as possible."

"The tube is placed in the brain to monitor pressure caused by fluid. There are risks, but the benefits support more effective treatments." Rationale: ICP monitoring devices may be placed in the ventricular cavity in the center of the brain; in the subdural cavity, the subarachnoid cavity, and the parenchyma (brain tissue). The intraventricular catheter is useful as it accurately measures pressures to provide data on how the brain is managing various activities such as changes in the vascular and respiratory systems secondary to the patient's pathology, patient's activities, provider interventions, etc. The combined data produced as a result of these changes is considered an index. This index is represented as a waveform. There are risks associated with these devices. The best nursing response addresses the question of risk while providing a brief explanation of the benefits. See pp. 663-665.

The nurse is reviewing laboratory values and notes that a patient will soon begin treatment for diabetes mellitus. Which glycosylated hemoglobin (A1C) level is on the patient's medical record? 1.7% 3.4% 5.2% 6.8%

6.8% Rationale: According to the American Diabetes Association diagnostic criteria, a hemoglobin A1C greater than or equal to 6.5% indicates diabetes mellitus. The other laboratory values do not support the diagnosis of diabetes mellitus because they are below 6.5%.

During a physical examination the nurse assesses a patient with hypothyroidism as having a goiter. What physiologic process caused the thyroid gland to enlarge? An increased dietary iodine intake A compensatory effort to produce more TH An excess of TH that stimulated thyroid follicles Tissue hypertrophy in response to increased TH

A compensatory effort to produce more TH Rationale: When TH production decreases, the thyroid gland enlarges in a compensatory attempt to produce more hormone. The goiter that results is usually a simple or nontoxic form. People living in certain areas of the world where the soil is deficient in iodine, the substance necessary for TH synthesis and secretion, are more prone to become hypothyroid and develop simple goiter. In hypothyroidism the development of a goiter is associated with a lack of dietary iodine intake. A goiter does not develop because of excessive TH stimulating thyroid follicles. A goiter that develops in response to increased levels of TH is seen in hyperthyroidism.

The nurse is preparing to instruct a patient with type 1 diabetes mellitus on the complication of diabetic ketoacidosis. Which pathologic process should the nurse review with the patient about this complication? A decreased amount of glucagon causes low protein levels. An excess amount of insulin drives all glucose into the cells. A deficit of insulin causes fat stores to be used as an energy source. An increase occurs in the breakdown of glucose molecules with hypoglycemia.

A deficit of insulin causes fat stores to be used as an energy source. Rationale: Diabetic ketoacidosis (DKA) develops when there is a deficiency of insulin; this results in glucose deficiency at the cellular level. As the pathophysiology of untreated type 1 DM continues, the glucose deficit causes fat stores to break down to provide energy, resulting in mobilization of fatty acids with a subsequent ketosis. The lack of cellular glucose causes production of counterregulatory hormones. Glucose production by the liver increases, peripheral glucose use decreases, fat mobilization increases, and ketogenesis is stimulated. As a result of a loss of bicarbonate, which occurs when the ketone is formed, bicarbonate buffering does not occur, leading to metabolic acidosis. Diabetic ketoacidosis is not caused by decreased glucagon, low protein levels, excessive insulin, or a breakdown of glucose molecules.

7. A nursing plan of care for a patient in diabetic ketoacidosis (DKA) includes altered tissue perfusion. Why is this an appropriate nursing diagnosis? A) Decreased extracellular fluid volume leads to decreased tissue perfusion through anaerobic metabolism. B) Kussmauls respirations cause panting and water loss through evaporation. C) Ketoacidosis causes respiratory acidosis D) Low blood pH shifts the oxyhemoglobin dissociation curve to the left, causing poor tissue oxygenation

A) Decreased extracellular fluid volume leads to decreased tissue perfusion through anaerobic metabolism.

14. A patient with severe thyrotoxicosis has a very high temperature. What medication or treatment is least appropriate to suppress the temperature? A) Acetylsalicylic acid (aspirin) B) Acetaminophen (Tylenol) C) Cooling blanket D) Intravascular cooling system

A) Acetylsalicylic acid (aspirin)

A patient in diabetic ketoacidosis (DKA) is to receive insulin to control blood sugar. What type of insulin does the nurse expect to administer? A) Intravenous drip regular B) Subcutaneous regular C) Intravenous Lantis D) Subcutaneous Lantis

A) Intravenous drip regular

8. A nursing plan of care for a patient who is hypoglycemic includes which of the following? A) Monitoring neurologic status changes B) Monitoring temperature status changes C) Monitoring cardiac status changes D) Monitoring blood alcohol levels

A) Monitoring neurologic status changes

Patients experiencing DKA (diabetic ketoacidosis) demonstrate a much higher level of ketoacidosis than patients experiencing HHS (hyperosmolar hyperglycemic state). Why does this occur? A) Patients with HHS produce just enough insulin to prevent ketosis. B) Only patients with Type 1 diabetes experience ketoacidosis. C) HHS develops too quickly to build up a high level of ketoacidosis. D) The fluid loss in HHS is too mild to allow a high level of ketoacidosis.

A) Patients with HHS produce just enough insulin to prevent ketosis.

Which of the following descriptive words are indicative of myxedema coma? A) Rare, hypothyroid B) Chronic, hypothyroid C) Common, hyperthyroid D) Rare, hyperthyroid

A) Rare, hypothyroid

6. Most endocrine disorders are not diagnosed until patients are acutely ill with a second condition. What are some common precipitating illnesses these patients may have? A) Severe illness/stress activating the HPA axis B) High glucose levels from gluconeogenesis C) Low cortisol levels from depleting the flight or fight response D) Decreased basal metabolic rate from prolonged hyperthermia

A) Severe illness/stress activating the HPA axis

Which laboratory studies would be conducted for Mr. Blew to monitor his diabetes management? (Select all that apply.) A. Fasting blood glucose B. Glycosylated hemoglobin (Hb A1c) C. Complete blood cell count D. Serum electrolytes E. Serum cholesterol and triglyceride levels

A. Fasting blood glucose B. Glycosylated hemoglobin (Hb A1c) D. Serum electrolytes E. Serum cholesterol and triglyceride levels Rationale: Laboratory tests used to monitor diabetes management are fasting blood glucose levels, glycosylated hemoglobin, abnormal electrolyte levels indicating DKA or HHS, and cholesterol levels to monitor for increased risk of cardiovascular impairments.

A nurse is reviewing laboratory results for a client who has Addison's disease. Which of the following laboratory results should the nurse expect for this client? (Select all that apply.) A. Sodium 130 mEq/L B. Potassium 6.1 mEq/L C. Calcium 11.6 mg/dL D. Blood urea nitrogen (BUN) 28 mg/dL E. Fasting blood glucose 148 mg/dL

A. Sodium 130 mEq/L: This finding is below the expected reference range. In the presence of Addison's disease, insufficient glucose can cause sodium and water excretion. Hyponatremia is an expected finding. B. Potassium 6.1 mEq/L: This finding is above the expected reference range. Hyperkalemia is an expected finding for a client who has Addison's disease. C. Calcium 11.6 mg/dL: This finding is above the expected reference range. Hypercalcemia is an expected finding for a client who has Addison's disease. D. Blood urea nitrogen (BUN) 28 mg/dL: This BUN level is above the expected reference range, which is an expected finding for a client who has Addison's disease due to dehydration. E. This finding is above the expected reference range for a fasting blood glucose level. Hypoglycemia or blood glucose in the normal range is an expected finding for a client who has Addison's disease.

A nurse is providing medication teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply.) A. Take the medication on an empty stomach. B. Notify the provider of any illness or stress. C. Report any manifestations of weakness or dizziness. D. Do not discontinue the medication suddenly. E. Eat a low-sodium diet.

A. The client should take hydrocortisone with food to decrease GI distress. B. Notify the provider of any illness or stress: Physical and emotional stress increase the need for hydrocortisone. The provider can increase the dosage when stress occurs. C. Report any manifestations of weakness or dizziness: Weakness and dizziness are indications of adrenal insufficiency. The client should report these indications to the provider. D. Do not discontinue the medication suddenly: Rapid discontinuation can result in adverse effects, including acute adrenal insufficiency. If hydrocortisone is to be discontinued, the dose should be tapered. E. Addison's disease causes hyponatremia. The client might require sodium supplementation, especially if experiencing diaphoresis or vomiting.

3. Which of the following are precipitating factors for thyrotoxic crisis? Select all that apply. A) Infection B) Hypothermia C) Steroid therapy D) Long, chronic illness E) Pregnancy

ALL ARE CORRECT

The nurse is teaching a patient with type 1 diabetes mellitus how to self-administer the daily prescribed insulin. In which body area should the nurse teach that the most rapid absorption of the medication occurs? Hip Thigh Deltoid Abdomen

Abdomen Rationale: Although in theory any area of the body with subcutaneous tissue may be used for injections of insulin, certain sites are recommended. The rate of absorption and peak of action of insulin differ according to the site. The site that allows the most rapid absorption is the abdomen, followed by the subcutaneous tissue of the upper arm, thigh, and hip. Insulin sites are rotated within a given region with each injection.

What type of traumatic brain injury (TBI) occurs when a head in motion strikes a stationary object? Contrecoupe injury Acceleration injury Rotational injury Acceleration-deceleration injury

Acceleration-deceleration injury

The patient diagnosed with DKA has collaborative diagnoses of impaired gas exchange and ineffective breathing pattern. Which of the following interventions is INAPPROPRIATE for these diagnoses? Provide supplemental oxygen, and mobilize when feasible. Monitor ABGs, pulse ox, and breathing pattern. Administer vasopressors as ordered. Provide chest physiotherapy regularly.

Administer vasopressors as ordered. Rationale: The patient with DKA is likely to experience metabolic acidosis which may result in damage to the brain stem's respiratory center resulting in an inability to properly ventilate and respire. Interventions may include chest physiotherapy, turning, coughing, deep breathing, mobilizing, monitoring, providing oxygen, etc. The cause of the impaired gas exchange would not be directly impacted by vasopressors, although vasopressors may be indicated if the patient becomes hypotensive which is likely with dehydration associated with DKA. See Box 44-9.

The nurse is caring for a client experiencing thyrotoxicosis. What should the nurse include in the plan of care for this client? Assessing fluid status while preparing the patient for surgical removal of the adrenal tumor. Administering antipyretics, tepid bathing, and obtaining a cooling blanket. Administering levothyroxine (Synthroid), obtaining a cooling blanket, and maintaining a calm environment. Observing for adverse side effects of iodine preparations, and treating for constipation.

Administering antipyretics, tepid bathing, and obtaining a cooling blanket. Rationale: Thyrotoxicosis or thyroid storm involves excessive amounts of thyroid hormone in the blood. This causes high fever, tachycardia, and elevated BP. Morton, pp. 866

Mr. J is diagnosed with thyrotoxicosis. In addition to the physician addressing the excessive thyroid hormones, the nurse addresses the potential impact to the patient. This includes anticipation of which of the following nursing interventions? Observing for adverse side effects of iodine preparations, and treating for constipation. Administering antipyretics, tepid bathing, and obtaining a cooling blanket. Administering hormone replacement, obtaining a cooling blanket, and maintaining a calm environment. Assessing fluid status while preparing the patient for surgical removal of the adrenal tumor.

Administering antipyretics, tepid bathing, and obtaining a cooling blanket. Rationale: thyrotoxicosis is a severe form of hyperthyroidism characterized by excessive metabolic responses, cardiovascular collapse, and neurological dysfunction. Hyperthermia is a likely and potentially fatal symptom and necessitates nursing interventions to reduce the fever. Hormone replacement is appropriate for myxedema, constipation is more likely in hypothyroidism, and if there is a tumor stimulating excessive thyroid hormones, it would be on the pituitary, not the adrenal gland. A tumor on the adrenal gland may cause excessive catecholamines resulting in Pheochromocytoma. See pp. 864-869.

The nurse is providing education to the community on spinal cord injuries. The nurse teaches that the most important prevention against spinal injury is: Where a helmet when horseback riding. Practicing safety on ladders. Use proper mechanics when lifting. Always use seatbelts in the car.

Always use seatbelts in the car. Rationale: Most spinal cord injuries are caused by MVAs and extreme activates such as diving and contact sports.

The client with a spinal cord injury suddenly appears excessively diaphoretic, is flushed, and complains of a pounding headache. Vital signs are B/P of 182/110 mm Hg, temperature of 100.6 degree F, heart rate of 50 bpm, and respirations of 24 breaths per minute. The nurse understand these are signs of which of the following complications? Neurogenic Shock Compartment Syndrome Pulmonary Embolus Autonomic Dysreflexia

Autonomic Dysreflexia

The patient with a SCI injury at T7 appears suddenly excessively diaphoretic, is flushed, and complains of a pounding headache. The patient's V/S are B/P of 182/110 mm Hg, and TPR of 100.6, 50, and 24. The nurse proceeds to perform a series of interventions based on the suspicion of which of the following complications? Neurogenic Shock Pulmonary Embolus Compartment Syndrome Autonomic Dysreflexia

Autonomic Dysreflexia Rationale: Autonomic Dysreflexia (or hyperreflexia) is a serious complication which may occur as a result of an inappropriate response by the Autonomic Nervous System (ANS) to a trigger causing reflexive vasoconstriction of the blood vessels. The vasoconstriction causes hypertension and a throbbing headache. The increase in blood pressure stimulates compensatory mechanisms to decrease blood pressure by reducing the heart rate (bradycardia), and dilating vessels (causing flushing). This phenomenon is triggered automatically by situations which stimulate the ANS below the site of injury. Triggers include a full bladder, straining during a bowel movement, pain, cold or hot stimuli, and others (see Box 37-5). Nursing interventions can reduce the episode and prevent further damage (see Box 37-7). See pp. 745-746.

9. A patient in HHS (hyperosmolar hyperglycemic state) has a serum glucose of 900, serum osmolarity of 400, and an anion gap of 8. Treatment for this condition includes which of the following? A) Administer intravenous normal saline as quickly as possible. B) Correct the fluid deficit with intravenous normal saline at a moderate rate. C) Administer a high-dose insulin drip. D) Administer sodium bicarbonate to correct the acidosis.

B) Correct the fluid deficit with intravenous normal saline at a moderate rate.

23. A patient with type 1 diabetes mellitus is being discharged home after an episode of diabetic ketoacidosis (DKA). What should the nurse most emphasize in discharge teaching? A) Insulin therapy may be discontinued after several months. B) The patient needs supplemental insulin even when not eating. C) Blood sugar is best regulated by use of long-lasting insulin preparations. D) Blood sugar can be regulated by diet if the patient is very careful.

B) The patient needs supplemental insulin even when not eating.

Loss involuntary (phrenic) and voluntary (intercostal) respiratory function; require tracheostomy and ventilatory support: Spinal injury?

C1-C4

What are the MOST severe spinal cord injuries?

C1-C4

A patient with hyperthyroidism is being treated with propylthiouracil and potassium iodide. When giving these medications, what precaution should the nurse take? A) Check apical pulse before administration. B) Check serum potassium before administration. C) Administer medications at least 1 hour apart. D) Give medications intravenously.

C) Administer medications at least 1 hour apart.

16. A patient has been diagnosed with primary hypoadrenalism (Addisons disease). What usually destroys the adrenal gland tissues? A) Mycobacterium tuberculosis B) Septic shock hemorrhage C) Autoimmune antibodies D) Metastatic malignancies

C) Autoimmune antibodies

24. A 40-year-old insulin-dependent diabetic is becoming increasingly stuporous. He is pale, diaphoretic, and tachycardic. What is the most important strategy the nurse expects to be included in the initial treatment? A) Low-dose insulin infusion B) Bolus of high-dose insulin C) Bolus of 50% dextrose D) Fluid replacement

C) Bolus of 50% dextrose

25. A middle-aged patient with diabetes mellitus type 2 is being treated for hyperosmolar hyperglycemic syndrome, which developed from an infection. During discharge teaching, the nurse emphasizes what concept? A) Reduce use of insulin when ill. B) Exercise moderately. C) Increase frequency of glucose testing when ill. D) Increase amount of carbohydrates in diet.

C) Increase frequency of glucose testing when ill.

In spinal cord injuries, what vertebrae are injured cause no bladder or bowel "control"?

C1-C6 T6-T12 L1-L4

What vertebrae correspond control of arms and hands, may be able to breath on own and speak?

C5-C8

In spinal cord injuries, what vertebrae are injured cause no bladder or bowel "function"?

C7 C8 T1-T6

10. A patient was resuscitated from a cardiopulmonary arrest and is now being managed with mechanical ventilation, an intravenous amiodarone drip, an angiotensin-converting enzyme (ACE) inhibitor, and a beta-adrenergic antagonist. The patient has severe tachycardia, tachypnea, diaphoresis, temperature above 104F, frequent premature ventricular contractions, clear lung fields, normal oxygen status, and agitation and restlessness. What complication and cause does the nurse suspect? A) Septic shock from ventilator-acquired pneumonia B) Hypovolemia from cardiopulmonary arrest C) Thyrotoxic crisis from amiodarone use D) Adverse reaction to ACE inhibitor

C) Thyrotoxic crisis from amiodarone use

The nurse is reviewing the lab values for a client with suspected bacterial meningitis. Which findings in the cerebral spinal fluid (CSF) would be consistent with this diagnosis? Clear fluid with increased glucose level Cloudy fluid with decreased glucose content Clear fluid with decreased level of protein Cloudy fluid with decreased white blood cell count (WBC)

Cloudy fluid with decreased glucose content Rationale: CSF indicators of meningitis in cloudy fluid with marked increase in WBC and protein and decreased glucose.

The nurse is monitoring the respiratory pattern of an elderly patient in ICU. The nurse notes a pattern of progressively deeper breaths followed by increasingly more shallow breaths resulting in a temporary cessation of breath. What is the MOST appropriate response by the nurse? Continue monitoring with the understanding that this pattern is common in the critically ill patient. Request a neurology consult to determine causation. Complete a neurologic and respiratory assessment, and then report pertinent findings. Initiate a code because the pattern represents brain herniation and impending death.

Complete a neurologic and respiratory assessment, and then report pertinent findings. Rationale: Cheyne's-Stokes is a pattern caused by impairment in the respiratory function of the brain. It may be evidence of dying, of worsening cerebral edema (ICP), severe CHF, and other pathologic conditions. It may also be associated with the elderly without a known cause. Therefore, it would be appropriate, without knowing the patient's diagnosis (es), to assess for other significant abnormalities, and report. See p. 719-720, and 434 (as a review).

While reviewing a medication list, the nurse learns that a new patient has taken cortisone as treatment for rheumatoid arthritis for several years. What endocrine disorder is the patient most at risk for developing? Acromegaly Hypothyroidism Hyperthyroidism Cushing's syndrome

Cushing's syndrome Rationale: Cushing's syndrome is a chronic disorder in which hyperfunction of the adrenal cortex produces excessive amounts of circulating cortisol or ACTH. The disorder also may occur as the result of pharmacologic therapy (iatrogenic Cushing's). People who take steroids for long periods of time are at increased risk for developing the disorder. Acromegaly is caused by overproduction of growth hormone. Cortisone treatment for rheumatoid arthritis will not lead to the development of hypo- or hyperthyroidism.

15. A patient has been admitted to the critical care unit in myxedema coma. What patient description does the nurse most expect? A) Young man with abdominal trauma B) Middle-aged man with skeletal trauma C) Middle-aged woman in summer D) Elderly woman during winter

D) Elderly woman during winter

In spinal cord injuries, what vertebrae are injured for a patient to have "possible" bladder or bowel control?

L4-S5

The patient has been diagnosed with hyperthyroidism. What laboratory result would the nurse least expect to be elevated? A) Total thyroxine (T4) B) Free triiodothyronine (T3) C) Free thyroxine (T4) D) Thyroid stimulating hormone (TSH)

D) Thyroid stimulating hormone (TSH)

Cushing's triad of symptoms is a reflex to increased ICP. Symptoms include a widening pulse pressure (increased SBP), bradycardia, and an abnormal respiratory pattern. The symptoms are indicative of which of the following conditions: Strongly correlated to subdural hematomas. Decompensation and impending brainstem herniation. Autoregulation indicating effective compensatory mechanisms. Highly indicative of damage to the frontal lobe.

Decompensation and impending brainstem herniation. Rationale: Cushing's syndrome is a collection of symptoms caused by an attempt to increase blood flow to the brain due to the impairment of blood flow caused by edema pressing on the vasculature. The reflex ("Cushing's Reflex") is part of an attempt to autoregulate cerebral blood flow; but due to the pathology of increased ICP, the increased pressure actually causes greater risk of damage to the brain. Various parts of the brain may herniate, but the most likely tissue is the brainstem. Once Cushing's Triad is evident, brainstem herniation is imminent causing irreversible brain damage and death. See pp. 662-663.

Which is a neurological age-related change in the older adult client that make them more susceptible to falls and head injuries? Elevated blood pressure and metabolism Decreased response to balance changes More focused on activities Increased cerebral blood flow

Decreased response to balance changes

The nurse is concerned that a patient is showing signs of hypercalcemia. What did the nurse assess in this patient? Oliguria Positive Chvostek's sign Diminished bowel sounds Hyperactive deep tendon reflexes

Diminished bowel sounds Rationale: Increased serum calcium decreases neuromuscular excitability, which decreases bowel motility. Manifestations of the effect of hypercalcemia on the gastrointestinal tract include constipation. Hypercalcemia does not affect urine output. A positive Chvostek's sign is a manifestation of hypocalcemia. Deep tendon reflexes are hyperactive in hypocalcemia, not hypercalcemia.

A client is being treated on an acute care unit after a traumatic brain injury (TBI). The nurse knows stimulation of the sympathetic nervous system (SNS) after an acute TBI could cause which of the following manifestations? Select All that Apply Dysrhythmias Decreased respiratory rate Decreased metabolism Hypertension Diuresis

Dysrhythmias Hypertension Increased metabolism of carbs, fats, and proteins Retention of sodium and water Peripheral constriction, or "Systemic vascular resistance (SVR)" Tachypnea Hypertension EEG changes Dysrhythmias (bradycardia, sinus tachycardia)

A client has been admitted to the critical care unit in myxedema coma. What client description does the nurse most expect? Middle-aged man with skeletal trauma Middle-aged woman in summer Elderly woman during winter Young man with abdominal trauma

Elderly woman during winter

The nurse reports the following findings for the patient with tetraplegia from a spinal cord injury (SCI) at T4: V/S are B/P 110/60, and TPR are 99.4, 88, 32, with a pulse ox of 80%. Considering the serious complications of this type of injury, what would the nurse anticipate as a PRIORITY intervention for this patient? Pain Management Nutritional support Room temperature management Endotracheal Intubation

Endotracheal Intubation Rationale: Respiratory complications are the leading cause of death. Respiratory failure is anticipated if the VC is less than 15-20 mL/kg and the respiratory rate is greater than 30 breaths per minute. If the pulse ox is less than 85 mm Hg, or if PaCO2 is greater than 45 mm Hg, intubation may be warranted (see. P. 741). Although pain is common, thermic dysregulation is a complication, and malnutrition is common, the patient imminent risk is respiratory failure.

A female patient with Cushing's syndrome is distressed because of the appearance of abdominal stretch marks. What should the nurse explain to the patient about this skin change? Excessive mineralocorticoids reduce the absorption of calcium. Excessive glucocorticoids affect normal carbohydrate metabolism. Excessive glucocorticoids cause a loss of collagen and connective tissue. Excessive cortisol results in changes in protein metabolism and protein catabolism.

Excessive glucocorticoids cause a loss of collagen and connective tissue. Rationale: In a patient with Cushing's syndrome the skin becomes thinner, leading to the development of abdominal striae or stretch marks. This is due to the inhibition of fibroblasts by excessive glucocorticoids, leading to a loss of collagen and connective tissue. Excessive mineralocorticoids that reduce the absorption of calcium cause osteoporosis and compression fractures. Excessive cortisol changes protein metabolism and protein catabolism, which leads to muscle weakness and wasting. Excessive glucocorticoids affect normal carbohydrate metabolism and cause fat deposits in the abdomen, under the clavicles, over the upper back, and a round "moon" face.

The nurse is caring for a client with Type 1 diabetes receiving insulin. The nurse checks on the client and notices the client is confused, shaky and diaphoretic. What should the nurse do first? Administer next dose of regular insulin Assess the client's vital signs Ask the assistive personnel to obtain a blood sugar Have the client drink 6 ounces of juice

Have the client drink 6 ounces of juice Rationale: The client is showing signs of hypoglycemia and should be given a form of glucose such as juice or soda. Blood sugar and vitals may be taken but the immediate need is to correct the hypoglycemia.

Which of the following collaborative interventions should the nurse anticipate in caring for Mr. Blew's diabetic ketoacidosis? A. Preparing a continuous vasopressin infusion B. Obtaining an order for blood glucose levels every 2 to 4 hours C. Initiating a continuous infusion of regular insulin mixed in 5% dextrose/water D. Instituting an intravenous infusion of 0.9% normal saline at a rate of 250 mL/h.

Instituting an intravenous infusion of 0.9% normal saline at a rate of 250 mL/h. Rationale: The hyperglycemia of DKA results in osmotic diuresis, which leads to dehydration and loss of electrolytes. If left untreated, fluid volume deficit leads to poor perfusion and lactic acidosis, further complicating the metabolic acidosis. The initial fluid replacement may be accomplished by administering 0.9% saline solution at high infusion rates to replace losses from polyuria and vomiting.

A client has been admitted to the critical care unit in myxedema coma. What should the nurse consider ensuring is readily available? Morphine sulfate to treat pain Protamine sulfate Intravenous (IV) metoprolol Intubation tray

Intubation tray Rationale: Client in myxedema coma are at high risk for respiratory arrest and an intubation tray an ventilation system should be available. Morphine will exacerbate the respiratory depression, metoprolol will decrease already low blood pressure. Protamine sulfate is for heparin overdose.

A patient who is prescribed insulin for diabetes control is scheduled for surgery in the morning. What should the nurse anticipate regarding the prescribed morning regular insulin dose? It will be given intravenously. It should be chilled to slow absorption. It will be given at the usual prescribed dose. It should be combined with long-acting insulin

It will be given at the usual prescribed dose. Rationale: No intermediate- or long-acting insulin is given the day of surgery since dietary intake postoperatively is uncertain. Unless otherwise ordered, regular insulin is given at the usual dose to compensate for the anticipated stress-related increase in serum glucose until the patient is eating and drinking normally. If there is no food intake after surgery, intravenous dextrose is often prescribed with subcutaneous regular insulin. The insulin should not be chilled to slow absorption. The insulin does not need to be provided through the intravenous route.

The nurse is planning care for a client with meningitis and at risk for increased intracranial pressure (ICP). What actions should the nurse include in the plan of care for this client? Perform focused neurological assessment every 8 hours Administer opiates every 2 hours for neck pain Encourage the client to cough frequently Maintain calm environment and turn off room lights

Maintain calm environment and turn off room lights Clients with meningitis and risk for increased ICP should minimize brain activity to reduce the risk of seizures and increased pressure from blood flow. Neuro assessments should be frequent, opiates should be avoided as it will mask symptoms of increased ICP and coughing is avoided as it increases ICP.

The patient diagnosed with diabetic ketoacidosis has a nursing diagnosis of ineffective breathing pattern. The nurse should include all of the following in the plan of care EXCEPT: Maintain client on bedrest. Monitor arterial blood gases. Provide ordered supplemental oxygen as needed. Encourage use of incentive spirometer.

Maintain client on bedrest. Rationale: Clients with DKA are at risk for respiratory failure and should be monitored and provided supplemental O2 as ordered. Turning, coughing, deep breathing and incentive spirometer are important to prevent complications. Bedrest is not recommended and ambulation to ability could improve respiratory status. Morton, pp. 883

The nurse is the emergency department is caring for a client with cervical spinal cord injury. What is the priority of care for this client? Provide fluids to ensure adequate blood pressure Maintain effective breathing pattern Assess motor function and extent of paralysis Prepare client for computerized topography (CT) exam

Maintain effective breathing pattern Clients with cervical injury are at risk for respiratory distress and breathing is a nursing care priority.

Which goal is a priority for the diabetic patient who is taking insulin and has nausea and vomiting for a few days from a virus? Proper rest and sleep Maintaining an exercise routing Relieving pain Maintaining adequate nutrition

Maintaining adequate nutrition All are important, but nutrition and insulin administration are the priority at this time.

The nurse is caring for a client with a spinal cord injury who has developed a paralytic ileus. What should the nurse expect to be ordered for this client? Clear liquid diet Electrocardiogram (ECG) Endotracheal Intubation Nasogastric decompression

Nasogastric decompression Paralytic ileus is a GI disturbance where the motility of the intestines ceases. The client is placed NPO with NG suctioning and decompression.

The nurse is creating the plan of care for a client who is hypoglycemic. Which assessment is a priority for the nurse to monitor? Temperature status changes Blood alcohol levels Neurologic status changes Cardiac status changes

Neurologic status changes

The nurse is assessing a client with suspected meningitis for Brudzinski's sign. Which is an appropriate action to take while performing this assessment? Straighten the client's leg and lift above the level of the heart Flex the client's hip and knee simultaneously Place hand behind the neck and bend the neck towards the chest Place the client in the side-lying position with knees bent towards chest

Place hand behind the neck and bend the neck towards the chest Brudzinski's sign is used in assessing for meningitis. The nurse would place a hand on the back of the neck and flex the head and neck towards the chest. A positive sign causes the hip and leg flexion. The client is positioned supine.

Which of the following can affect the accuracy of glucose meter performance for self-monitoring of blood glucose? (Select all that apply.) A. Presence of dehydration B. Adequate blood sample on the test strip C. Proper training on use of the blood glucose meter D. Use of excessive isopropyl alcohol to clean the skin E. Test strips that have been stored outside the original container

Presence of dehydration Use of excessive isopropyl alcohol to clean the skin Test strips that have been stored outside the original container

The patient has been identified with a severe accelerated-decelerated injury of the brain from a MVA. During endotracheal suction, the patient becomes visibly agitated, tachycardic, diaphoretic, and begins to present a flexed posture. What is the BEST intervention by the nurse? Avoid endotracheal suction, and encourage the patient to cough. Administer the prescribed anti-anxiety, and narcotic. Monitor and document signs of repeated or worsening symptoms. Reduce environmental stimuli, and communicate findings to the physician.

Reduce environmental stimuli, and communicate findings to the physician. Rationale: Paroxysmal sympathetic hyperactivity (sympathetic storming) may be triggered by a stressful event and caused by an imbalance in the activity of the SNS to activity of the PSNS. Although the imbalance may last, medication may lessen the risk of episodes and therefore communicating findings to the physician is warranted. See p. 723.

The nurse is preparing an insulin infusion for a patient in diabetic ketoacidosis (DKA). Which type of insulin should the nurse use to make this intravenous infusion? NPH Regular Glargine Humalog

Regular Rationale: Regular insulin is clear in appearance and is used for subcutaneous injection as well as IV insulin therapy. Other insulins such as NPH, glargine, and Humalog are suspensions and could be harmful if given by the IV route. Regular insulin is used in insulin infusions, as an IV bolus, or subcutaneous by itself or in combination with intermediate-acting insulins to provide better glucose control.

Emergency treatment of status epilepticus includes all of the following except: Provide oxygen if ordered and available. Loosening restrictive clothing. Turning the patient on the side to help maintain a patent airway. Restraining the patient to prevent injury.

Restraining the patient to prevent injury. Airway should be maintained by loosening clothing around the neck, turning to the side to prevent secretions from pooling and providing O2 if available. Clients should no be restrained as this could cause more injury during seizures

What injured vertebrae injured result in loss function in hips and legs, little or no control bowel/bladder, likely to be able to walk?

S1-S5

In spinal cord injuries, what vertebrae are injured for a patient to have control of bowel continence?

S3-S5

A client is admitted to the emergency department after a traumatic brain injury from a motor vehicle accident (MVA). The client was awake and alert on arrival. What manifestation would indicate the client is experiencing an acute subdural hematoma? Sudden headache Severe hypertension Increase in urine output Pinpoint pupils

Sudden headache

What vertebrae correspond nerves affect muscles of upper chest, mid-back, and abdominal muscles, arm and hand function usually normal, paraplegia (legs affected)?

T1-T5

Phrenic nerve functions independently with some impairment of intercostal muscles occurs in what injured vertebrae?

T1-T6

What vertebra affects muscles trunk, paraplegia, normal upper-body movement, no control bowel and bladder?

T6-T12

In spinal cord injuries, what vertebrae injured cause NO INTERFERENCE with respiratory function?

T6-T12 L1-L4 L4-S5

If Mr. Blew's blood glucose drops to 50 mg/dL, which manifestations might he exhibit? A. Bradycardia, nausea, and vomiting B. Tachycardia, hypotension, and shakiness C. Thirst, diarrhea, and fatigue D. Hypertension, edema, and dyspnea

Tachycardia, hypotension, and shakiness Rationale: Signs and symptoms of hypoglycemia are tachycardia, hypotension, and shakiness

A patient is admitted to the ICU after a traumatic brain injury from a motor vehicle accident (MVA). The patient's ABG's are as follows: pH 7.25, pCO2 65, HCO3 26. What is the MOST likely effect of the patient's gases upon the traumatized brain? The patient's ABGs represent hypoventilation increasing the risk of cerebral vasoconstriction. The ABG's represent a risk factor for increasing cerebral edema secondary to vasodilation. The patient's ABG's represent hyperventilation increasing the risk of cerebral edema. The ABG's are the result of poor respiratory effort, and does not affect cerebral blood flow.

The ABG's represent a risk factor for increasing cerebral edema secondary to vasodilation. Rationale: The auto-regulatory system of the brain is designed to maintain normal cerebral blood flow (CBF) by maintaining cerebral perfusion pressure (CPP). CPP is affected by CO, MAP, SBP, and ICP, as well as the ability of the cerebral vessels to dilate or constrict in response to changes in these pressures. These are the key factors in autoregulation of the CBF. Hypercapnia, hypoxia, and brain trauma impact the ability of the cerebral vessels to dilate or constrict. CO2 is a potent cerebral vasodilator which causes an increase in CBF, which then increases blood volume resulting in increased ICP. See Cerebral Blood Flow section on p. 660.

An adult client with a generalized seizure disorder is experiencing seizure activity. The nurse comes in and sees the client having alternating contractions with relaxation of the extremities and hyperventilation. The nurse knows the client is in which phase of a seizure? The tonic phase The absence phase The clonic phase The postictal phase

The clonic phase The client with generalized seizures can have absent or tonic-clonic seizures. The clonic phase is characterized by periods of alternating contractions with relaxation of the extremities and hyperventilation.

A patient with hyperthyroidism is scheduled to receive radioactive iodine. What should the nurse explain about the use of radioactive iodine in hyperthyroidism? The thyroid gland takes up iodine in any form. Radioactive iodine reduces the vascularity of the thyroid gland. Irradiation of the thyroid gland decreases the risk of hypothyroidism. Doses of radioactive iodine are too small to be hazardous to other body parts.

The thyroid gland takes up iodine in any form. Rationale: Because the thyroid gland takes up iodine in any form, radioactive iodine (131I) concentrates in the thyroid gland and damages or destroys thyroid cells so that they produce less thyroid hormone. Radioactive iodine is given orally and the patient will see results in 6 to 8 weeks. The patient is not hospitalized during treatment and does not require radiation precautions. This type of therapy is contraindicated in pregnant women because radioactive iodine crosses the placenta and can have negative effects on the developing fetal thyroid gland. Because the amount of gland destroyed is not readily controllable, the patient may develop hypothyroidism and require lifelong thyroid hormone replacement therapy. Adverse reactions include thyroiditis and cardiac instability due to liberation of stored thyroid hormone in the gland. Radioactive iodine does not impact the vascularity of the thyroid gland

The nurse is preparing a teaching session on insulin for a group of patients newly diagnosed with type 1 diabetes mellitus. Which safety feature should the nurse emphasize when discussing insulin glargine (Lantus) and insulin detemir (Levemir)? These insulins are clear like regular insulin. These insulins are activated by vigorous agitation. These insulins are combined with glucose to raise energy levels. These insulins are subject to being inactivated by light and must be kept cold.

These insulins are clear like regular insulin. Rationale: Insulin glargine (Lantus) and insulin detemir (Levemir) are clear, unlike other intermediate or long-acting insulins, and can accidentally be mistaken for regular insulin. Regular insulin is short acting in 4 to 6 hours whereas Lantus and Levemir are long acting over 24 to 28 hours. These insulins are not activated by vigorous agitation. They are not combined with glucose to raise energy levels. These insulins are also not inactivated by light and must be kept cold.

The nurse is caring for a client diagnosed with symptomatic adrenal insufficiency. Which signs and symptoms should the nurse expect on assessment? Bradycardia and bradypnea Weight gain and hypertension Weakness and fatigue Constipation and increased appetite

Weakness and fatigue

The nurse is caring for a client diagnosed with symptomatic adrenal insufficiency. Which signs and symptoms should the nurse expect on assessment? Weight loss and hypertension Constipation and hypernatremia Hypotension and bradycardia Weakness and hyperkalemia

Weakness and hyperkalemia Rationale: Adrenal insufficiency cause severe hypotension, tachycardia, weight loss, weakness, fatigue, hyperkalemia and hyponatremia.

A client with a seizure disorder is being discharged with a new prescription for gabapentin (Neurontin). What should the nurse include in the discharge education? Take with an antacid if you have gastric distress Only take the medication when you feel an aura Wear an medical identification bracelet at all times Yellowing of the eyes is a normal side effect of this medication

Wear an medical identification bracelet at all times

The primary difference between whether a client with a diabetic hyperglycemic emergency is developing hyperosmolar hyperglycemic state (HHS) or diabetic ketoacidosis (DKA) is which of the following? If the client is dehydrated, and needs insulin therapy. Whether the client is insulin resistance or insulin dependent. If the client is at risk for severe complications of coma and possible death. Whether the client has been following appropriate sick day rules.

Whether the client is insulin resistance or insulin dependent. Rationale: HHS is a complication of Type 2 or insulin resistant diabetes as there is no ketone accumulation in the blood due to the presence of insulin. DKA is a complication of Type 1 diabetics and includes ketones and acidosis from the lack of insulin.

The primary difference between whether a patient with a diabetic hyperglycemic emergency has HHS or DKA is which of the following? If the patient needs fluid resuscitation, and insulin therapy or not. If the patient is at risk for severe complications of coma and possible death. Whether the patient is insulin resistance, or has a severe deficiency of insulin. Whether the patient has been compliant with their medication regimen or not.

Whether the patient is insulin resistance, or has a severe deficiency of insulin. Rationale: People with Type 1 DM is at risk for DKA. In the absence of insulin, the body uses fat cells for energy producing ketosis. People with Type 2 DM may have severe insulin deficiency and also produce ketosis; but, if they are producing insulin and the diabetes is primarily a problem of resistance, the body will not burn fat for energy and therefore, will not produce ketosis. Consider the symptoms of fruity breath and other signs of DKA in Box 44-8, p. 880 relevant to the pathology; and compare this to the symptoms of HHS.

The nurse is reviewing the health histories of newly admitted patients for the risk of developing endocrine disorders. Which patient would be most at risk for the development of type 2 diabetes mellitus? Middle-aged man who maintains normal weight Woman age 70 who is overweight and sedentary Young adult who is a professional basketball player Middle-aged woman who is the sole caretaker of her parents

Woman age 70 who is overweight and sedentary Rationale: The risks for developing type 2 diabetes mellitus include increasing age, obesity, and a sedentary lifestyle. Of the newly admitted patients, the one who is at the highest risk for developing type 2 diabetes mellitus is the 70-year-old patient who is overweight and sedentary. Normal weight, active lifestyle, and stress level do not contribute to the risk of developing this endocrine disorder