Silvestri test 6

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 1.Wears a turban to cover the incision 2.Indicates that facial puffiness will be a permanent problem 3.Verbalizes that periorbital bruising will disappear over time 4.States an intention to purchase a hairpiece until hair has grown back

2 Rationale: After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

The nurse is performing an assessment on a client admitted to the nursing unit with a diagnosis of stroke (brain attack). On assessment, the nurse notes that the client is unable to understand spoken language. The nurse plans care, understanding that the client is experiencing impairment of which areas? 1. The occipital lobe 2. The auditory association areas 3. The frontal lobe and optic nerve tracts 4. Concept formation and abstraction areas

2 Rationale: Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1.Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury

2 Rationale: Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost because these fibers decussate after entering the cord. Options 1, 3, and 4 are not assessment findings in this syndrome.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse avoid when planning care for this client? 1. Using a Roto-Rest bed 2. Removing the weights to reposition the client 3. Assessment of the integrity of the weights and pulleys 4. Comparing the amount of prescribed traction with the amount in use

2 Rationale: Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with cervical tongs is placed on a Stryker frame or Roto-Rest bed. The nurse ensures that weights hang freely, and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care.

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even-tempered, is prone to outbursts of temper now. The nurse counsels the family on the basis of an understanding that these behaviors are indicative of which condition? 1. Indicate a worsening of the original injury 2. Will probably be a long-term sequela of the injury 3. Will come and go as intracranial pressure changes 4. Are short-term problems that will resolve in about 1 month

2 Rationale: Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation.

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? 1.Tightened screws 2.Red skin areas under the jacket 3.Clean and dry lamb's wool jacket lining 4.Finger-width space between the jacket and the skin

2 Rationale: Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket. The screws all should be properly tightened. A clean, dry lamb's wool lining should be in place underneath the jacket, and there should be a finger-width space between the jacket and the skin. In addition, the client should wear a clean white cotton T-shirt next to the skin to help prevent itching.

A client has sustained damage to Wernicke's area in the temporal lobe from a brain attack (stroke). Which should the nurse anticipate when caring for this client? 1.The client will be unable to recall past events. 2.The client will have difficulty understanding language. 3.The client will demonstrate difficulty articulating words. 4.The client will have difficulty moving one side of the body.

2 Rationale: Wernicke's area consists of a small group of cells in the temporal lobe the function of which is the understanding of language. The hippocampus is responsible for the storage of memory (the client will be unable to recall past events). Damage to Broca's area is responsible for aphasia (the client will demonstrate difficulty articulating words). The motor cortex in the precentral gyrus controls voluntary motor activity (the client will have difficulty moving one side of the body).

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? 1. In 15 degrees of Trendelenburg 2. Side-lying with the head of the bed flat 3. With the head of the bed elevated at least 30 degrees 4. With the head of the bed elevated no more than 10 degrees

3 Rationale: Positioning of the client correctly following cranial surgery is important to avoid increased intracranial pressure and to promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is always followed. The client with an incision in the anterior or middle fossa should be positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in the posterior fossa or burr holes have been made, the client is positioned flat, or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is performed, the client should not be positioned to the operative side. Trendelenburg position is contraindicated in the postoperative phase following cranial surgery.

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia)

4 Rationale: Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What important nursing intervention is necessary for this client? 1. Take and record vital signs every 4 to 8 hours. 2. Prophylactically hyperventilate during the first 20 hours. 3. Treat a central fever with the administration of antipyretic medications such as acetaminophen (Tylenol). 4. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4 Rationale: Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during the first 20 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

The nurse is performing an assessment on a client with a diagnosis of thrombotic brain attack (stroke). Which assessment question would elicit data specific to this type of stroke? 1."Have you had any headaches in the past few days?" 2."Have you recently been having difficulty with seeing at nighttime?" 3."Have you had any sudden episodes of passing out in the past few days?" 4."Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

4 Rationale: Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on one side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because the client's speech will be characteristic of which finding? 1.Intact 2.Rambling 3.Characterized by literal paraphasia 4.Associated with poor comprehension

4 Rationale: Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.

A mother arrives at an emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and the nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1.Nausea 2.Irritability 3.Headache 4.Bradycardia

4 Rationale: Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased intracranial pressure (ICP). In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field."

4 Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

The nurse is preparing a plan of care for a client with a diagnosis of brain attack (stroke). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? 1.The client will be easily fatigued. 2.The client will have difficulty speaking. 3.The client will have difficulty swallowing. 4.The client will exhibit neglect of the affected side.

4 Rationale: In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. Options 1, 2, and 3 are not associated with anosognosia.

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? 1.Temperature 2.Blood pressure 3.Ability to speak 4.Level of consciousness

4 Rationale: Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by performing which action? 1. Keeping the client on a stretcher 2. Logrolling the client onto a soft mattress 3. Logrolling the client onto a firm mattress 4. Placing the client on a bed that provides spinal immobilization

4 Rationale: Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. Options 1, 2, and 3 are incorrect and potentially harmful interventions.

The nurse has developed a nursing care plan for a client with a burn injury. The client problem states deficient fluid volume. Which intervention should the nurse include in the plan of care as a priority intervention? 1. Monitor vital signs every 4 hours. 2. Monitor mental status every hour. 3. Monitor intake and output every shift. 4. Obtain and record weight every other day.

2 Rationale: In a client with deficient fluid volume secondary to a burn injury, vital signs should be monitored every hour (every 4 hours is too infrequent) until the client is hemodynamically stable. The nurse should monitor the mental status of the client every hour for the first 48 hours. The weight should be obtained and recorded daily or twice daily, and intake and output measurements should be recorded on an hourly basis.

An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half of a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that most likely what will be the initial treatment? 1. Dialysis 2. The administration of an emetic 3. The administration of vitamin K 4. The administration of sodium bicarbonate

2 Rationale: Initial treatment of acetylsalicylic acid overdose includes the administration of an emetic or gastric lavage. Activated charcoal may be administered to decrease absorption. Fluids and sodium bicarbonate may be administered intravenously to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin sodium (Coumadin) overdose.

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with acute brain attack (stroke) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? 1.Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 2.Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 3.Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 4.Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

2 Rationale: The client's airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The correct option is the only one that meets all three criteria.

Which finding indicates a burn client is adequately fluid resuscitated? 1.Disorientation to time only 2.Heart rate of 95 beats/minute 3.+1 palpable peripheral pulses 4.Urine output of 30 mL over the last 2 hours

2 Rationale: When fluid resuscitation is adequate, the heart rate should be less than 120 beats/min, as indicated in option 2. Additionally, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hr, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position

3 Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Options 1, 2, and 4 are incorrect

The mother of a 3-year-old boy reports to poison control that she found an empty bottle of acetaminophen (Tylenol) on the floor. She states she thinks her child ingested all the medication. What is the priority question for the nurse to ask the mother? 1. "Is your child breathing okay?" 2. "Is your child alert and oriented?" 3. "Where is your child at this moment?" 4. "Do you know how many tablets were in the bottle?"

1Rationale: Airway is always the highest assessment data to obtain during a poison control call. Once this information is obtained, the child's neurological status can be determined in terms of his orientation and other information, such as that related to options 2, 3, and 4.

The nurse witnesses the collapse of a victim in her neighborhood and suspects cardiac arrest. Which action should the nurse take first? 1. Initiate rescue breathing. 2. Begin giving chest compressions. 3. Activate the emergency response system. 4. Obtain an automated external defibrillator.

3 Rationale: If a collapse is witnessed and the nurse suspects cardiac arrest, the nurse should first activate the emergency response system. Next, the nurse should obtain an automated external defibrillator, followed by initiation of cardiopulmonary resuscitation, beginning with chest compressions.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence? 1.Strict adherence to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Preventing unnecessary pressure on the lower limbs 4.Limiting bladder catheterization to once every 12 hours

4 Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A 2-year-old child is admitted to a hospital burn unit with partial- and full-thickness burns involving 35% of body surface area. After admission assessment and review of the health care provider's prescriptions, the priority nursing intervention should focus on which action? 1. Inserting a Foley catheter 2. Inserting a nasogastric tube 3.Sedating with morphine sulfate 4. Restricting intravenously administered fluids

1 Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be measured accurately each hour. A nasogastric tube may or may not be required, but this is not the priority intervention. Although pain medication may be required, the child should not be sedated. Intravenously administered fluids are not restricted and are administered at a rate sufficient to keep the child's urine output at 1 mL/kg of body mass per hour, thus reflecting adequate tissue perfusion.

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1. Blood pressure 2. Motor response 3. Pupillary response 4. Level of consciousness

1 Rationale: Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. Options 2, 3, and 4 are unrelated to monitoring for Cushing's reflex.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4. Cranial nerves only, such as speech and pupillary response

1 Rationale: Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? 1. Keep the client on NPO status. 2. Allow the client to have full liquids. 3. Give the client small glasses of clear liquids. 4. Order the client a full meal tray with extra liquids.

1 Rationale: The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? 1.Gastric lavage 2.Intravenous (IV) fluid therapy 3.Nothing by mouth (NPO) status 4.Preparation for laboratory studies

1 Rationale: The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should avoid which action? 1.Giving the client thin liquids 2.Thickening liquids to the consistency of oatmeal 3.Placing food on the unaffected side of the mouth 4.Allowing plenty of time for chewing and swallowing

1 Rationale: The client with dysphagia is started on a diet only after the gag and swallow reflexes have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1. Gastric pH of 3 2.Absence of abdominal discomfort 3. GI drainage that is guaiac negative 4. Presence of hypoactive bowel sounds

1 Rationale: The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.

The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition? 1. Normal condition 2. Increased pressure 3. Borderline situation 4. Compensating condition

1 Rationale: The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1.Sounds will not be heard clearly unless they are loud. 2.Obtain assistance with ambulation if client is lightheaded. 3.Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4. Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1 Rationale: The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

2Rationale: Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels

4 Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse attempts to relieve an airway obstruction in a 3-year-old conscious child. The nurse performs the abdominal thrust maneuver correctly by standing behind the child, placing her arms under the child's axillae and around the child, and positioning her hands to deliver the thrusts between which areas? 1. Groin and the abdomen 2. Umbilicus and the groin 3. Lower abdomen and the chest 4. Umbilicus and the xiphoid process

4 Rationale: To perform abdominal thrusts on a child, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The rescuer places the thumb side of one fist against the victim's abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrusts. One must take care not to touch the xiphoid process or the lower margins of the rib cage because force applied to these structures may damage internal organs.

A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 1. Pain medication 2. Endotracheal intubation 3. Oxygen via nasal cannula 4. 100% humidified oxygen by face mask

4 Rationale: With a smoke inhalation injury, the client is immediately treated with 100% humidified oxygen delivered by face mask. This method provides a greater concentration of oxygen than oxygen delivered via nasal cannula. Endotracheal intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. Pain medication may be needed but would not be the initial intervention.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue

1 Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 1. Hematocrit 60% 2. Serum albumin 4.8 g/dL 3. Serum sodium 144 mEq/L 4. White blood cell (WBC) count 9000 cells/mm3

1 Rationale: Extensive burns greater than 25% of the TBSA result in generalized body edema in both burned and unburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels are elevated in the first 24 hours after injury as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit level ranges from 42% to 52%, depending on gender. Options 2, 3, and 4 identify normal laboratory values.

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? 1. Removing all clothing, including gloves and shoes 2. Determining the antidote for the chemical and placing the antidote on the burn site 3. Leaving all clothing in place until the client is brought to the emergency department 4. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing

1 Rationale: In a chemical burn injury the burning process continues as long as the chemical is in contact with the skin. All clothing, including gloves and shoes, is removed immediately, and water lavage is instituted before and during the transport to the emergency department. Powdered chemicals are first brushed off the client before lavage is performed.

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and submerged into a local river. What is the initial action of the nurse? 1. Call the nursing supervisor to activate the agency disaster plan. 2. Supply the triage rooms with bottles of sterile water and normal saline. 3. Call the intensive care unit to request that nurses be sent to the emergency department. 4.Call the laundry department, and ask the department to send as many warm blankets as possible to the emergency department.

1 Rationale: In an external disaster many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the nurse would take, the initial action would be to activate the disaster plan.

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1. Notify the health care provider (HCP). 2. Place the child in a supine position. 3. Place the child in Trendelenburg's position. 4. Increase the flow rate of the intravenous fluids.

1 Rationale: In the event of shock, the HCP is notified immediately before the nurse changes the child's position or increases intravenous fluids. After craniotomy, a child is never placed in the supine or Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. The head of the bed should be elevated. Increasing intravenous fluids can cause an increase in ICP.

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 1. Bradycardia 2. Hyperthermia 3. Hypoglycemia 4. Increased cardiac output

1 Rationale: Neurogenic shock can occur after a spinal cord injury. Usually the body attempts to compensate massive vasodilation by becoming tachycardic to increase the amount of blood flow and oxygen delivered to the tissues; however, in neurogenic shock, the sympathetic nervous system is disrupted, so the parasympathetic system takes over, resulting in bradycardia. This insufficient pumping of the heart leads to a decrease in cardiac output. Hypoglycemia is not an indicator of neurogenic shock. Hypothermia develops because of the vasodilation and the inability to control body temperature through vasoconstriction.

The nurse has developed a client problem of ineffective airway clearance for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? 1. Elevate the head of the bed. 2. Monitor oxygen saturation levels every 4 hours. 3. Encourage coughing and deep breathing every 4 hours. 4. Assess respiratory rate and breath sounds every 4 hours.

1 Rationale: Nursing interventions for the client with an inhalation burn injury include assessing the respiratory rate every hour, monitoring oxygen saturation levels every hour, and assisting the client in coughing and deep breathing every hour. The head of the bed is elevated to facilitate lung expansion.

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? 1.Cooling the injury with water 2. Removing all clothing immediately 3. Removing the tar from the burn injury 4. Leaving any clothing that is saturated with tar in place

1 Rationale: Scald burns and tar or asphalt burns are treated by immediate cooling with water, if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene.

The nurse is developing a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1.Thicken liquids. 2.Assist the client with eating. 3.Assess for the presence of a swallow reflex. 4.Place the food on the affected side of the mouth. 5.Provide ample time for the client to chew and swallow.

1,2,3,5 Rationale: Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.

Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply. 1. Monitor vital signs. 2. Monitor neurological status. 3. Monitor the dressing for signs of infection. 4. Monitor for signs of increased intracranial pressure. 5. Drain cerebrospinal fluid when the intracranial pressure is elevated.

1234Rationale: A subarachnoid bolt is inserted into the subarachnoid space and is used to measure intracranial pressure. Because a subarachnoid bolt is placed in the subarachnoid space, it is not capable of draining cerebrospinal fluid, which is produced in the ventricles. Therefore option 4 is not an intervention. Options 1, 2, 3, and 4 are appropriate interventions

The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? 1. Urine output of 40 mL/hr 2. Heart rate of 110 beats/min 3. Frequent premature ventricular contractions 4. Central venous pressure (CVP) of 15 mm Hg

1Rationale: Urine output of greater than 30 mL/hr indicates adequate perfusion to the kidneys, so the other organs are most likely equally perfused. Classic cardiovascular signs of cardiogenic shock include low blood pressure and tachycardia. Dysrhythmias commonly occur as a result of decreased oxygenation to the myocardium and are not a favorable sign. The CVP rises as the effects of the backward blood flow caused by the left ventricular failure became apparent.

The mother of a 5-year-old boy is brought to the emergency department after ingesting a bottle of acetylsalicylic acid (ASA). Which procedure should be initially instituted with this child? 1. Administer ipecac by mouth and monitor emesis. 2. Institute a gastric lavage and administer activated charcoal. 3. Administer a chelating agent such as calcium disodium edetate (calcium EDTA). 4. Institute a gastric lavage and administer the antidote acetylcysteine (Mucomyst).

2 Rationale: A gastric lavage must be performed after ingestion of ASA and activated charcoal is administered to prevent further absorption of the substance. N-acetylcysteine is the antidote for acetaminophen. Options 1 and 3 are not treatment measures for ASA poisoning. Calcium EDTA may be prescribed for the treatment of lead poisoning. Ipecac causes vomiting, and this substance is used only in specific poisoning conditions; in this situation, vomiting can cause irritation of the esophagus.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1.A victim experiencing excruciating pain 2.A victim experiencing airway obstruction 3.A victim experiencing moderate anxiety 4. A victim experiencing altered level of consciousnes

2 Rationale: Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately? 1. Reinforce the dressing. 2. Notify the health care provider (HCP). 3. Document the findings and continue to monitor. 4. Circle the area of drainage and continue to monitor.

2 Rationale: Colorless drainage on the dressing in a child after craniotomy indicates the presence of cerebrospinal fluid and should be reported to the HCP immediately. Options 1, 3, and 4 are not the immediate nursing intervention because they do not address the need for immediate intervention to prevent complications.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1.Superficial 2.Full-thickness 3.Deep partial-thickness 4.Partial-thickness superficial

2 Rationale: Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. The nurse should take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties.

2 Rationale: In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the emergency department for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur

A client who previously suffered a burn injury now exhibits a keloid at the burn site. The nurse plans care, knowing that this lesion is caused by hypertrophy of which part of the dermis? 1. Nerves 2. Collagen 3. Vasculature 4. Subcutaneous tissue

2 Rationale: Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1.Vital signs 2.Urine output 3.Mental status 4.Peripheral pulses

2 Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? 1. White color 2. Pink or red color 3. Weeping blisters 4. Insensitivity to pain and cold

2 Rationale: Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign/symptom? 1. Coma 2. Flushing 3.Dizziness 4. Tachycardia

2 Rationale: The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% result in coma and death.

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2,3,5 Rationale: The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock. The client is kept warm and placed on NPO status because of the altered gastrointestinal function that occurs as a result of a burn injury.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1.Clustering nursing activities 2.Hyperoxygenating before suctioning 3.Maintaining 20 degree flexion of the knees 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

2,4,5 Rationale: Measures aimed at preventing increased ICP in the post-stroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intra-abdominal pressure and consequently ICP.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. 1.A client with dyspnea 2.A client experiencing sinus rhythm 3.A client receiving oral anticoagulants 4.A client with chronic atrial fibrillation 5.A client experiencing third-degree heart block 6.A client who has not voided since before surgery

234Rationale: Clients should be medically stable if discharged and should be able to manage their condition at home independently, with family assistance, or with community services. The client in option 2 is stable because sinus rhythm is a normal finding. Oral anticoagulants can be taken at home as long as the client understands how to take the medication and is provided with education about the medication. The client in option 4 can be discharged because the client's condition is chronic, not acute. The client experiencing dyspnea is not considered stable. The client in third-degree heart block is considered unstable and will most likely need a pacemaker insertion. Clients should not be discharged after surgery until they have voided

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1. Pain level 2. Lung sounds 3. Ability to swallow 4. Laboratory results

2Rationale: The priority nursing action would be to assess lung sounds. Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and cause erythema and edema of the airways and mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury.

Which client should the emergency department triage nurse classify as emergent? 1. A client with a displaced fracture who is crying 2. A client with a simple laceration and soft tissue injury 3. A client with crushing substernal pain who is short of breath 4. A client with a temperature of 101° F with a productive cough

3 Rationale: A triage method commonly used in the emergency department consists of three categories: emergent, urgent, and nonurgent. The emergent category implies that a condition exists that poses an immediate threat to life or limb. An example of a client who fits into this category is the client experiencing crushing substernal pain who is short of breath. The urgent category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. The client with a displaced fracture who is crying and the client with a temperature of 101° F and productive cough would fit into this category. The nonurgent category indicates that the client can generally tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple laceration and soft tissue injury would fit into this category

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1.18% 2.24% 3. 36% 4. 48%

3 Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.

A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? 1. Pain 2. Fear 3. Hypoxia 4. Anxiety

3 Rationale: After a burn injury, clients normally are alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and also may occur after an electrical injury. Although anxiety, fear, and pain may occur, confusion and combativeness are most likely associated with hypoxia.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains dextrose in water

3 Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. Blood replacement is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because it would not replace needed fluid. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Dextrose in water is an isotonic solution, and an isotonic solution maintains fluid balance. This type of solution may be administered after the first 24 hours following the burn injury, depending on the client's physiological needs.

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 1. Heart failure 2. Pulmonary edema 3. Cardiogenic shock 4. Aortic insufficiency

3 Rationale: IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of the IABP is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary edema.

The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method? 1. Flexed position 2. Head tilt-chin lift 3. Jaw thrust maneuver 4. Modified head tilt-chin lift

3 Rationale: If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.

A nurse receives a telephone call from a neighbor, who states that her 3-year-old child was found sitting on the kitchen floor with an empty bottle of liquid furniture polish. The mother of the child tells the nurse that the bottle was half full, that the child's breath smells like the polish, and that spilled polish is present on the front of the child's shirt. What should the nurse tell the mother to do? 1. Call the pediatrician. 2. Induce vomiting immediately. 3. Call the poison control center. 4. Wait until the nurse comes to bring the child to the emergency department.

3 Rationale: If a poisoning occurs, the poison control center should be contacted immediately. Calling the pediatrician would not be the immediate action because this would delay treatment. Additionally, the pediatrician would immediately make a referral to the poison control center. Vomiting should not be induced if the victim is unconscious or the substance ingested was a strong corrosive or a petroleum-based product. The poison control center may advise the mother to bring the child to the emergency department, and if this is the case, the mother should call an ambulance.

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? 1. Assessing heart rate 2. Assessing respiratory rate 3. Assessing peripheral pulses 4. Assessing blood pressure (BP)

3 Rationale: The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment would be to assess for peripheral pulses to ensure that adequate circulation is present. Although the respiratory rate and BP also would be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses.

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The nurse documents this assessment finding as expected because the edema is caused by which factor? 1. A decrease in capillary permeability and hypoproteinemia 2. A decrease in capillary permeability and hyperproteinemia 3. An increase in capillary permeability and hypoproteinemia 4. An increase in capillary permeability and hyperproteinemia

3 Rationale: In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused by the volume and oncotic pressure effects of the large fluid resuscitation volumes required.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. The 32-year-old pregnant woman who exclaims, "My baby is not moving." 2. The 2-year-old standing next to an adult family member screaming, "I want my mommy!" 3. The 4-year-old complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 4. The 88-year-old who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

3 Rationale: Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The 2-year-old is with a family member and is safe at this time. The 88-year-old woman will need comfort measures; there is no information indicating she is physically hurt.

The community health nurse is working with disaster relief after a tornado. The nurse's goal for the community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed are all examples of which level of prevention? 1. Primary level of prevention 2. Secondary level of prevention 3. Tertiary level of prevention 4. Quaternary level of prevention

3 Rationale: Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis. There is no known quaternary prevention level.

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1. Spinal shock 2. Pulmonary embolism 3. Autonomic dysreflexia 4. Malignant hyperthermia

3 Rationale: The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of the seventh thoracic vertebra (T7). Autonomic dysreflexia is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. The data in the question are not associated with the conditions noted in options 1, 2, and 4.

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage, the nurse should attend to the client with which problem first? 1. Fractured tibia 2. Penetrating abdominal injury 3. Bright red bleeding from a neck wound 4. Open massive head injury in deep coma

3 Rationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving greater than 25% of total body surface area. In performing the assessment, the nurse knows that the maximum amount of edema that occurs from a burn normally is noted at which time frame? 1. Immediately after the injury 2. Within 12 hours after the injury 3. Between 18 and 24 hours after the injury 4. Between 42 and 72 hours after the injury

3 Rationale: The maximum amount of edema in a client with a burn injury is seen between 18 and 24 hours after the injury. With adequate fluid resuscitation the transmembrane potential is restored to normal within 24 to 36 hours after the burn. Options 1, 2, and 4 are incorrect.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A middle-aged man with one foot trapped under the wreckage 2. A crying teenager who is holding pressure on an arm laceration 3. A young woman who appears dazed and confused and is shivering 4. A screaming middle-aged woman looking frantically for her husband

3 Rationale: The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival.

The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4° F orally 3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/minute

3 Rationale: Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore the nurse would report the results of the blood pressure to the HCP before initiating therapy

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1.Unchanged weight 2.Shift intake 950 mL, output 900 mL 3.Blood urea nitrogen (BUN) 10 mg/dL 4.Serum osmolality 280 mOsm/kg H2O

4 Rationale: After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL is within normal range and does not indicate overhydration or underhydration.

The nurse in the emergency department is caring for a client who was in a motor vehicle crash and is experiencing hypovolemic shock. A pneumatic antishock garment (PASG), also known as shock trousers, is applied for treatment until the client can be transferred to the intensive care unit (ICU). While awaiting client transfer to the ICU, the emergency department nurse should perform which critical assessment? 1.Assessing radial pulses 2. Monitoring hemoglobin and hematocrit levels 3. Assessing vascular status of the upper extremities 4. Monitoring vascular status of the lower extremities

4 Rationale: A PASG may be useful in the treatment of hypovolemic shock associated with traumatic injury to provide circulatory assistance. The device is used only as a temporary measure until definitive treatment is given because it can compromise blood flow to the lower half of the body. The critical nursing assessment includes monitoring the vascular status of the lower extremities. Although options 1, 2, and 3 may be components of the nursing assessment, these actions are not part of the critical assessment required with use of a PASG.

A client is diagnosed with a full-thickness burn. The nurse plans care, knowing that which structural areas of the skin are involved? 1.Epidermis only 2.Epidermis and deeper dermis 3.Epidermis and upper layer of dermis 4.Epidermis, entire dermis, and epithelial portion of subcutaneous fat

4 Rationale: A full-thickness burn involves the epidermis, entire dermis, and epithelial portion of subcutaneous fat layer. Options 1, 2, and 3 describe superficial, moderate partial-thickness, and deep partial-thickness burns, respectively.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4 Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 1.1200 mL of 5% dextrose in water solution 2.2400 mL of 0.45% normal saline solution 3.4800 mL of 0.9% normal saline solution 4.9600 mL of lactated Ringer's solution

4 Rationale: The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/minute 3. Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4 Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Options 1, 2, and 3 are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and malaise 2. A client who twisted her ankle when she fell while rollerblading 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4 Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number 3 priority.

A child is receiving succimer (Chemet) for the treatment of lead poisoning. A nurse should monitor which most important laboratory result? 1. Iron level 2. Calcium level 3. Red blood cell count 4. Blood urea nitrogen level

4 Rationale: Succimer is a medication that is used to treat lead poisoning. Renal function (blood urea nitrogen and creatinine) is monitored closely during the administration of chelation therapy because the medication is excreted via the kidneys. Although it is important to monitor the iron level, calcium level, and red blood cell count, these results are not specific to chelation therapy, so are not the most important lab values to monitor.

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? 1. Concussion 2. Skull fracture 3. Subdural hematoma 4. Epidural hematoma

4 Rationale: The changes in neurological signs from an epidural hematoma begin with loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebrospinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1.The entire period of time during which rehabilitation occurs 2. The period from the time the client is stable until all burns are covered with skin 3.The period from the time the burn was incurred to the time when the client is admitted to the hospital 4.The period from the time the burn was incurred to the time when the client is considered physiologically stable

4 Rationale: The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.

The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition? 1. Skin color 2. Apical rate 3. Respiratory rate 4. Level of consciousness

4 Rationale: The neurological system is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. Although options 1, 2, and 3 would be a component of the assessment of the client with carbon monoxide poisoning, assessment of the neurological status of the client would elicit data specific to a deterioration in the client's condition.

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1. CO 5 L/min, PCWP low 2. CO 3 L/min, PCWP low 3. CO 4 L/min, PCWP high 4. CO 3 L/min, PCWP high

4 Rationale: The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure.

A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when? 1. The family comes to visit. 2. The nurse needs to do physical care. 3. The health care provider makes rounds. 4. The results of spinal radiography are known.

4 Rationale: There is a significant association between cervical spine injury and head injury. For this reason, the nurse leaves any form of spinal immobilization in place until spinal radiographs rule out fracture or other damage. Therefore options 1, 2, and 3 are incorrect.

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? 1. Keep the window blinds open. 2. Turn on a small spotlight above the client's head. 3. Make sure the door to the room is open at all times. 4. Prohibit or limit the use of a radio or television and reading.

4Rationale: Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or minimize increases in intracranial pressure. For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. The nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means are allowed with approval of the health care provider.

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCPs) prescriptions and should contact the HCP to question which prescription? 1.Suction as needed. 2. Obtain daily weight. 3. Provide clear liquid intake. 4. Maintain a patent intravenous line.

1 Rationale: A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications if necessary.

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which complication? 1.Altered breathing pattern 2.Increased likelihood of injury 3.Ineffective oxygen consumption 4.Increased susceptibility to aspiration

1 Rationale: Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the focus of the questio

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1.Elevate the head of the bed. 2.Examine the rectum digitally. 3.Assess the client's blood pressure. 4.Place the client in the prone position.

1 Rationale: Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position.

A client has suffered damage to Broca's area of the brain. The nurse providing care for this client anticipates that which area will be affected? 1. Speech 2. Hearing 3. Balance 4. Level of consciousness

1 Rationale: Broca's area in the brain is responsible for the motor aspects of speech, through coordination of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in this area is aphasia. The items listed in the other options are not the responsibility of Broca's area.

A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1.Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils

1 Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand. A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to a stretcher or wheelchair

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1.Keep suction equipment at the bedside. 2.Elevate the head of the bed 30 degrees. 3.Keep the client lying in a supine position. 4.Keep the head and neck in good alignment. 5.Administer prescribed respiratory treatments as needed.

1,2,4,5 Rationale: The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

123 Rationale: Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating.The head of the client at risk for or with increased intracranial pressure should be positioned so that the head is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the neck or turning the head from side to side.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? 1.Extend the arms. 2.Extend the tongue. 3.Turn the head toward the nurse's arm. 4.Focus the eyes on the object held by the nurse.

2 Rationale: Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. Options 1, 3, and 4 do not test the function of cranial nerve XII.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2 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 occur.

A client was seen and treated in the hospital emergency department for treatment of a concussion. The nurse determines that the family needs reinforcement of the discharge instructions if they verbalize to call the health care provider (HCP) for which client sign or symptom? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4. Difficulty awakening

2 Rationale: A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the HCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

A nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse should immediately test the discharge for the presence of which substance? 1.Protein 2.Glucose 3.Neutrophils 4.White blood cells

2 Rationale: After a head injury, bleeding from the nose or ears necessitates further evaluation. A watery discharge from the nose (rhinorrhea) that tests positive for glucose is likely to be cerebrospinal fluid (CSF) leaking from a skull fracture. On noting watery discharge from the child's nose, the nurse should test the drainage for glucose using reagent strips such as Dextrostix. If the results are positive, the nurse will contact the health care provider. The items in options 1, 3, and 4 are not normally found in CSF.

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1."When did the injury occur?" 2."Was the client awake and talking right after the injury?" 3."What medications has the client received since the fall?" 4."What was the client's level of consciousness before the injury?"

2Rationale: Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

A nurse is testing the spinal reflexes of a client during neurological assessment. Which reflex will assist in determining that the client has an adequate spinal reflex? 1. Cough reflex 2. Withdrawal reflex 3. Accommodation reflex 4. Munroe-Kellie reflex

2Rationale: The withdrawal reflex is one of the spinal reflexes. It is an abrupt withdrawal of a body part in response to painful or injurious stimuli. The cough reflex is a brainstem-associated reflex. Accommodation reflex is associated with cranial nerve III and is part of the ocular motor system. Munroe-Kellie is not a reflex; it is a doctrine or a hypothesis addressing the cerebral volume relationships among the brain, the cerebrospinal fluid, and intracranial blood and their cumulative impact on intracranial pressure.

Acetazolamide (Diamox) is prescribed for a client hospitalized with a diagnosis of a supratentorial lesion. The nurse understands that which is the primary action of the medication? 1.Prevention of hypertension 2.Prevention of hyperthermia 3.Decrease in cerebrospinal fluid production 4.Maintenance of blood pressure adequate for cerebral perfusion

3 Rationale: Acetazolamide (Diamox) is a carbonic anhydrase inhibitor. It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production. Options 1, 2, and 4 are not actions of this medication.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1.Sudden loss of consciousness occurred. 2.Signs and symptoms occurred suddenly. 3.The client experienced paresthesias a few days before admission to the hospital. 4. The client complained of a severe headache, which was followed by sudden onset of paralysis.

3Rationale: Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with brain attack (stroke) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1. Notify the health care provider. 2. Loosen tight clothing on the client. 3. Place the client in a sitting position. 4. Check the urinary catheter tubing for kinks or obstruction.

3Rationale: The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Options 2 and 4 can then be done, and option 1 can be completed once initial interventions are done.

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measure would be a potentially unsafe component of the precautions? 1.Provide physical aspects of care. 2.Prevent pushing or straining activities. 3.Maintain the head of the bed at 15 degrees. 4.Limit caffeinated coffee to one cup per day.

4 Rationale: Aneurysm precautions include placing the client on bed rest (as prescribed) in a quiet setting. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.

The nurse is developing a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? 1. Place an eye patch on the left eye. 2. Place personal articles on the client's right side. 3. Approach the client from the right field of vision. 4. Instruct the client to turn the head to scan the right visual field.

4 Rationale: Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should plan to place the client in which position? 1.Prone 2.Supine 3.Semi-Fowler's with the hip and the neck flexed 4.Head of the bed elevated 30 degrees with the head in midline position

4 Rationale: The health care provider's prescriptions are always followed with regard to positioning the client after stroke. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain. Options 1, 2, and 3 are incorrect positions for clients with hemorrhagic stroke.

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1. Brain death 2.A cerebral lesion 3. A temporal lesion 4. An intact brainstem

4 ationale: Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

A client who had a brain attack (stroke) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? 1. Teach the client to scan the environment. 2. Place all objects within the left visual field. 3. Place all objects within the right visual field. 4. Ensure that the family brings the client's eyeglasses to hospital.

1 Rationale: Hemianopsia is blindness in half the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual-field deficit.

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? 1. Nausea 2. Papilledema 3. Decerebrate posturing 4. Alterations in pupil size

1 Rationale: Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1. Reduce environmental noise. 2. Allow visitors as desired by the client and family. 3. Cluster nursing activities to reduce the number of interruptions. 4. Awaken the client every 2 to 3 hours to monitor mental status.

1 Rationale: Nursing interventions to control the ICP include maintaining a calm, quiet, and restful environment. Environmental noise should be kept at a minimum. Visiting should be monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP.

The nurse is reviewing a chart for a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which finding should the nurse expect to note on assessment of the child? 1. Not easily arousable and limited interaction 2. Loss of the ability to think clearly and rapidly 3. Loss of the ability to recognize place or person 4. Awake, alert, interacting with the environment

1 Rationale: Obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Confusion indicates that the ability to think clearly and rapidly is lost. Disorientation indicates that the ability to recognize place or person is lost. Full consciousness indicates that the child is alert, awake, orientated, and interacts with the environment.

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client? 1.Encourage hourly coughing. 2.Assist with incentive spirometer. 3.Encourage hourly deep breathing. 4.Reposition gently side to side every 2 hours.

1 Rationale: With aneurysm precautions, any activity that could raise the client's intracranial pressure (ICP) is avoided. For this reason, activities such as straining, coughing, blowing the nose, and even sneezing are avoided whenever possible. The other interventions (repositioning, deep breathing, and incentive spirometry) do not provide added risk of increasing ICP and are beneficial in reducing the respiratory complications of bed rest.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1.Take the temperature. 2.Listen to breath sounds. 3.Observe for dyskinesias. 4.Assess extremity muscle strength.

2 Rationale: Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? 1. Buspirone (BuSpar) 2. Chlorpromazine (Thorazine) 3. Prochlorperazine (Compazine) 4. Fluphenazine (Prolixin Decanoate)

2 Rationale: Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Buspirone is an anxiolytic. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic.

The nurse should place a child who had a medulloblastoma brain tumor (infratentorial) removed in which position postoperatively? 1. Trendelenburg's 2. Flat, on either side 3. With the head of the bed elevated above heart level 4.With the head of the bed elevated in low Fowler's position

2 Rationale: If an infratentorial tumor has been removed, the child is positioned flat on either side. The pillow is placed behind the child's back for comfort and to maintain the position. The pillow is not placed behind the head because when the pillow is behind the head, proper alignment is not maintained, and this misalignment can impair circulation. The child should never be placed in a Trendelenburg's position (head down) because this position increases intracranial pressure. The head is elevated when the tumor is a supratentorial one.

The nurse is performing the oculocephalic response (doll's-eyes maneuver) test on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as for the head. How should the nurse document these findings? 1. Normal 2. Abnormal 3. Insignificant 4. Inconclusive

2 Rationale: In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.

The nurse is monitoring a child with burns during treatment for burn shock. The nurse understands that which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? 1. Skin turgor 2. Neurological assessment 3. Level of edema at burn site 4. Quality of peripheral pulses

2 Rationale: Sensorium is an accurate guide to determine the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of sensorium in the child. Options 1, 3, and 4 would not provide an accurate assessment of the adequacy of fluid resuscitation.

The nursing student is assigned to care for a child with a brain injury who has a temporal lobe herniation. The nursing instructor determines that the student needs to further research this type of injury if the student states that which finding is a characteristic of this type of herniation? 1.It can cause ipsilateral pupil dilation. 2.It produces compression of the sixth cranial nerve. 3.A shifting of the temporal lobe laterally across the tentorial notch occurs. 4.Flaccid paralysis, pupil fixation, and death can occur if the intracranial pressure continues to rise.

2 Rationale: Temporal lobe herniation or uncal herniation refers to a shifting of the temporal lobe laterally across the tentorial notch. This produces compression of the third cranial nerve and ipsilateral pupil dilation. If pressure continues to rise, flaccid paralysis, pupil fixation, and death will result.

The nurse has completed discharge instructions for a client with application of a halo device. Which action indicates that the client needs further clarification of the instructions? 1.Uses a straw for drinking 2.Drives only during the daytime 3. Uses caution because the device alters balance 4. Washes the skin daily under the lamb's wool liner of the vest

2 Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.

A client who suffered a stroke is prepared for discharge from the hospital. The health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What nursing action should the nurse include in the client's plan of care? 1.Implement ROM exercises to the point of pain for the client. 2.Consider the use of active, passive, or active-assisted exercises in the home. 3.Encourage the client to be dependent on the home care nurse to complete the exercise program. 4.Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued.

2 Rationale: The home care nurse must consider all forms of ROM for the client. Even a client with hemiplegia can participate in some components of rehabilitative care. In addition, the goal in home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach home care measures so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.

A nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. The nurse concludes that which area of the client's brain is functioning adequately? 1. Thalamus 2. Hypothalamus 3. Limbic system 4. Reticular activating system

2 Rationale: The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

The home care nurse is making a visit to a client who is wheelchair bound after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2.Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization

2 Rationale: The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

A client who experienced a brain attack (stroke) several months ago still exhibits some difficulty with chewing food. The nurse plans care, knowing that the client has residual dysfunction of which cranial nerve? 1. Vagus (cranial nerve X) 2. Trigeminal (cranial nerve V) 3. Hypoglossal (cranial nerve XII) 4. Spinal accessory (cranial nerve XI)

2 Rationale: The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.

A client is newly admitted to the hospital with a diagnosis of brain attack (stroke) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned? 1. Glaucoma 2. Emphysema 3. Hypertension 4. Diabetes mellitus

2 Rationale: The nurse should be most concerned about emphysema. The respiratory system is the priority in the acute phase of a brain attack (stroke). The stroke client is vulnerable to respiratory complications such as atelectasis and pneumonia. Because the client has complete hemiplegia (is unable to move) and has emphysema, these risks are very significant. Although options 1, 3, and 4 are important, they are not as significant as option 2.

The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign that would indicate that brainstem involvement occurred during the surgical procedure? 1.Inability to swallow 2. Elevated temperature 3. Altered hearing ability 4. Orthostatic hypotension

2 Rationale: Vital signs and neurological status are assessed frequently after surgical removal of a brain tumor. Special attention is given to the child's temperature, which may be elevated because of hypothalamic or brainstem involvement during surgery. A cooling blanket should be in place on the bed or readily available if the child becomes hyperthermic. Inability to swallow and altered hearing ability are related to functional deficits after surgery. Orthostatic hypotension is not a common clinical manifestation after brain surgery. An elevated blood pressure and widened pulse pressure may be associated with increased intracranial pressure, which is a complication after brain surgery, but is not related to brainstem involvement.

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult. 2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 4. The lower proportion of body fluid to mass in a child increases the risk of cardiovascular problems. 5. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

236Rationale: Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

The nurse is trying to communicate with a client with brain attack and aphasia. Which action by the nurse would be least helpful to the client? 1.Speaking to the client at a slower rate 2.Allowing plenty of time for the client to respond 3.Completing the sentences that the client cannot finish 4.Looking directly at the client during attempts at speech

3 Rationale: Clients with aphasia after brain attack often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.

The nurse is monitoring a child with a brain tumor for complications associated with increased intracranial pressure (ICP). Which finding, if noted by the nurse, would indicate the presence of diabetes insipidus (DI)? 1.Weight gain 2.Hypertension 3.High urine output 4.Urine specific gravity greater than 1.020

3 Rationale: DI can occur in a child with increased ICP. Weight gain, hypertension and a urine specific gravity greater than 1.020 are indications of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, not DI. A high urine output would be indicative of DI.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder

3 Rationale: Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

A client with a neurological problem is experiencing hyperthermia. Which measure would be least appropriate for the nurse to use in trying to lower the client's body temperature? 1.Giving tepid sponge baths 2.Applying a hypothermia blanket 3.Placing ice packs in the axilla and groin areas 4. Administering acetaminophen (Tylenol) per protocol

3 Rationale: Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

A client who has had a brain attack (stroke) is being managed on the medical nursing unit. At 0800, the client was awake and alert with vital signs of temperature 98° F orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? 1.Reorient the client. 2.Retake the vital signs. 3.Call the health care provider (HCP). 4. Administer an antihypertensive PRN.

3 Rationale: The important nursing action is to call the HCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions.

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? 1.A psychologist 2.A social worker 3.A neuropsychologist 4.A vocational rehabilitation specialist

3...

A nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are parts of the circle of Willis? Select all that apply. 1.Basilar artery 2.Vertebral artery 3.Anterior cerebral artery 4.Posterior cerebral artery 5.Anterior communicating artery

345Rationale: The circle of Willis is a ring of blood vessels located at the base of the brain. It is referred to as the anterior circulation to the brain and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches. The basilar artery and vertebral artery are not part of the circle of Willis. Rather, they are part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the posterior inferior cerebellar artery and the spinal arteries.

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1.Check cranial nerve functioning. 2.Determine the cause of the accident. 3.Draw blood for arterial blood gas analysis. 4.Perform a pulmonary wedge pressure measurement.

3Rationale: Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury. Options 1, 2, and 4 are not priorities although they may be a component in the assessment process, depending on the injury and client condition

The nurse is planning care for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1. Place the client in Sims position. 2. Change the drainage tubing every 48 hours. 3. Level the transducer at the lowest point of the ear. 4. Use strict aseptic technique when touching the monitoring system.

4 Rationale: Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. Sims is side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30% to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? 1.Serosanguineous only 2.Bloody with very small clots 3.Sanguineous only with no clot formation 4.Serosanguineous, surrounded by clear to straw-colored fluid

4 Rationale: CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (from the surgery) and surrounded by an area of clear or straw-colored drainage. The typical appearance of CSF drainage is that of a "halo." The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive

The nurse is preparing a plan of care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care knowing that this type of posturing indicates which finding? 1. Damage to the pons 2. Damage to the midbrain 3. Damage to the diencephalon 4. A lesion in the cerebral hemisphere

4 Rationale: Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1.Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2. The client has compulsive habits that should be ignored so long as they are not harmful. 3. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

4 Rationale: Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left. There is no information in the query of the question that would indicate that the client is anorexic, obsessive-compulsive, or has a slow metabolism.

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1. A history of diarrhea 2. A flattened abdomen 3. Hyperactive bowel sounds 4. Hematest-positive nasogastric tube drainage

4 Rationale: Development of a stress ulcer also can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool. The client is also at risk for paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. The nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in which structure? 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus

4 Rationale: Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus.

The nurse is developing a plan of care for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 1.Encourage communication. 2.Provide a consistent daily routine. 3.Promote adequate bowel elimination. 4.Increase the client's awareness of the affected side.

4 Rationale: In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side. Options 1, 2, and 3 are not associated with this deficit.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1.Had a very mild stroke 2.Most likely suffered a transient ischemic attack 3.May have difficulty with language abilities only 4.Is likely to have perceptual and spatial disabilities

4 Rationale: The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.

A client has sustained damage to Wernicke's area in the temporal lobe from a stroke (brain attack). The nurse anticipates that the client will have difficulty with which function? 1. Articulating words 2.Understanding language 3. Moving one side of the body 4. Recalling events in the remote past

2 Rationale: Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply. 1.Leave the lights on in the client's room at night. 2.Place a blood pressure cuff at the client's bedside. 3.Close the shades in the client's room during the day. 4.Allow the client to drink one cup of caffeinated coffee a day. 5.Allow the client to ambulate four times a day with assistance.

2,3 Rationale: Aneurysm precautions include placing the client on bed rest in a quiet setting. The use of lights is kept to a minimum to prevent environmental stimulation. The nurse should monitor the blood pressure and note any changes that could indicate rupture. Any activity, such as pushing, pulling, sneezing, or straining, that increases the blood pressure or impedes venous return from the brain is prohibited. The nurse provides physical care to minimize increases in blood pressure. Visitors, radio, television, and reading materials are restricted or limited. Stimulants, such as nicotine and coffee and other caffeine-containing products, are prohibited. Decaffeinated coffee or tea may be used.

A client has suffered a head injury affecting the occipital lobe of the brain. The nurse anticipates that the client may experience difficulty with which sense? 1. Smell 2. Taste 3. Vision 4. Hearing

3 Rationale: The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is a priority nursing intervention? 1. Assist the client to eat with the left hand to build strength. 2. Provide a pureed diet that is easy for the client to swallow. 3. Inform the client that a feeding tube will be placed if progress is not made. 4. Provide a variety of foods on the meal tray to stimulate the client's appetite.

1, Rationale: Right-sided hemiparesis is weakness of the right arm and leg. The nurse should teach the client to use both sides of the body to increase strength and build endurance. Option 2 is incorrect. The question does not mention swallowing difficulty, so there is no need to puree the food. Option 3 is incorrect. That information would come from the health care provider. Option 4 is incorrect. The problem is not the food selection but the client's ability to eat the food independently.

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which sign is an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. Mild drowsiness 2. Drooping eyelids 3. Ptosis of the left eyelid 4. Slight slurring of speech 5. Less frequent spontaneous speech

1,45Rationale: Early changes in LOC relate to orientation, alertness and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1. Position the client on his or her side. 2. Use products that contain alcohol. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges. 5. Use lemon glycerin swabs when performing mouth care.

134 Rationale: The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol should be avoided because they have a drying effect.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

3 Rationale: After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? 1.Emphasize progress in a realistic manner. 2.Set high goals to give the client something to "aim for." 3.Tell the family to be extremely optimistic with the client. 4.Inform the client and family of standardized goals of care.

1 Rationale: The most helpful approach by the nurse is to emphasize progress that is being made in a realistic manner. The nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse encourages the family to be realistic in their expectations and attitudes. The plan of care should be individualized for each client.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1.Insert nasal packing. 2.Document the findings. 3.Contact the health care provider (HCP). 4.Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3 Rationale: Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention. Options 1, 2, and 4 are inappropriate nursing actions in this situation.

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the health care provider (HCP). 4.Mark the area of drainage with a pen and monitor for further drainage.

3 Rationale: Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the HCP needs to be notified. Options 1, 2, and 4 are inappropriate nursing actions

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's-eyes maneuver) if which condition is present in the client? 1. Dilated pupils 2. Lumbar trauma 3. A cervical cord injury 4. Altered level of consciousness

3 Rationale: In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should avoid placing the client in which positions? 1.Head midline 2.Neck in neutral position 3.Flat, with head turned to the side 4.Head of bed elevated 30 to 45 degrees

3 Rationale: The client who is at risk for or with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 1.Ask the family to deliver the care. 2.Leave the client alone until ready to participate. 3.Advise the client that rehabilitation progresses more quickly with cooperation. 4.Acknowledge the client's anger and continue to encourage participation in care.

4 Rationale: Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1.Gets angry with family if they interrupt a task 2.Experiences bouts of depression and irritability 3.Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

4 Rationale: Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.