Care III Exam 4 Practice Questions

b. Cardiac dysrhythmia

A 56-year-old woman with Type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. Which finding will be the priority for the nurse to monitor? a. Elevated triglycerides b. Cardiac dysrhythmia c. Fatigue d. Hypoglycemia

b. Basilar skull fracture

A child is admitted with a head injury after being in a motor vehicle crash. After noting the presence of clear drainage from the left ear, the nurse should suspect which underlying problem commonly associated with this finding? a. Linear skull fracture b. Basilar skull fracture c. Subdural hematoma d. Epidural hematoma

c. "It must be difficult feeling as though there is no hope."

A client diagnosed with a terminal illness states, "What's left for me? I feel hopeless." The nurse determines that which of the following would be the best response? a. "It makes me feel sad that you feel hopeless." b. "Sometimes people in your situation get depressed, which makes them feel hopeless." c. "It must be difficult feeling as though there is no hope." d. "Can you think of one or two reasons to not feel so bad?"

c. Bargaining

A client with a terminal illness states, "If I could only live until I can walk my daughter down the aisle at her wedding, I will donate all of my money to research." The nurse reports that the client is in which phase of the grief process? a. Denial b. Seeking c. Bargaining d. Acceptance

c. Acute glomerulonephritis

A male client who presents to the emergency department with coffee-colored urine and edema states he had a sore throat a few weeks ago. His blood pressure is elevated and urinalysis shows blood and protein in the urine. The nurse interprets that this clinical picture is consistent with which developing health problem? a. Urinary tract infection b. Urinary calculi c. Acute glomerulonephritis d. Pancreatitis

d. Immobilize the patient's cervical spine

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

b. Clear fluid coming from the nares

A nurse in the ER is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basal skull fracture? a. Depressed fracture of the forehead b. Clear fluid coming from the nares c. Motor loss on one side of the body d. Bleeding from the top of the scalp

b. E3 + V4 + M4 = 11

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? a. E2 + V3 + M5 = 10 b. E3 + V4 + M4 = 11 c. E4 + V5 + M6 = 15 d. E2 + V2 + M4 = 8

b. Change in orientation c. Asterixis

A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply) a. Anorexia b. Change in orientation c. Asterixis d. Ascites

c. Increased urine output

A nurse is assessing a client who has increased intracranial pressure and has received IV Mannitol. Which of the following findings indicates a therapeutic effect of this medication? a. Decreased blood glucose b. Decreased bronchospasms c. Increased urine output d. Increased temperature

b. Cheyne-Stokes

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid, deep respirations followed by rapid, shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? a. Orthopnea b. Cheyne-Stokes c. Paradoxical d. Kussmaul

c. Inability to locate eyeglasses

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

b. Implement droplet precautions

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

a. Widened pulse pressure

A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? a. Widened pulse pressure b. Tachycardia c. Periorbital edema d. Decreased urine output

c. Level of consciousness

A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? a. Vital signs b. Body posture c. Level of consciousness d. Examination of pupils

a. The client's serum osmolality is 310 mOsm/L **Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue

A nurse is assessing a client with a closed head injury who has received Mannitol for manifestations of increased ICP. Which of the following findings indicates that the medication is having a therapeutic effect? a. The client's serum osmolality is 310 mOsm/L b. The client's pupils are dilated c. The client's HR is 56/min d. The client is restless

a. Place client in the supine position c. Place hands behind the client's neck d. Bend the client's head toward their chest

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

c. Dilated pupils

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased ICP? a. Battle's sign b. Periorbital edema c. Dilated pupils d. Halo sign

b. Infection

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ICP monitoring? a. Headache b. Infection c. Aphasia d. Hypertension

b. Respiratory effort

A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? a. Understanding speech b. Respiratory effort c. Decision-making ability d. Temperature control

c. Rigid skull containing cerebral contents

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased ICP. This increase in ICP is due to which of the following? a. Decreased cerebral perfusion b. Leakage of CSF c. Rigid skull containing cerebral contents d. Brain herniated into the brainstem

b. Decrease the noise level in the client's room d. Administer a stool softener

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16-22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply) a. Suction the endotracheal tube frequently b. Decrease the noise level in the client's room c. Elevate the client's head on two pillows d. Administer a stool softener e. Keep the client well-hydrated

a. The client rigidly extends his arms

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

b. Hyperkalemia

A nurse is caring for a client who has chronic glomerulonephritis. with oliguria. For which of the following electrolyte imbalances should the nurse monitor? a. Hypercalcemia b. Hyperkalemia c. Hypomagnesemia d. Hypophosphatemia

a. Diuretic b. Beta-blocker d. Lactulose

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply) a. Diuretic b. Beta-blocker c. Opioid analgesic d. Lactulose e. Sedative

b. Monitor VS every 2 hours c. Assess neuro status every 4 hours e. Keep the client's room darkened

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply) a. Place the client in respiratory isolation b. Monitor VS every 2 hours c. Assess neuro status every 4 hours d. Maintain the client in a modified Trendelenburg position e. Keep the client's room darkened

b. Hyponatremia

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a. Hyperglycemia b. Hyponatremia c. Hypervolemia d. Oliguria

c. Oxygen saturation

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? a. Glasgow coma scale b. Cranial nerve function c. Oxygen saturation d. Pupillary response

b. Assist the client to a supine position c. Administer an opioid medication d. Encourage the client to increase fluid intake

A nurse is caring for a client who is post-procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply) a. Use the Glasgow Coma Scale when assessing the client b. Assist the client to a supine position c. Administer an opioid medication d. Encourage the client to increase fluid intake e. Instruct the client to perform deep breathing and coughing exercises

a. Stop the transfusion c. Maintain an IV infusion with 0.9% NaCl e. Administer diphenhydramine

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? (Select all that apply) a. Stop the transfusion b. Monitor for hypertension c. Maintain an IV infusion with 0.9% NaCl d. Position the client in an upright position with the feet lower than the heart e. Administer diphenhydramine

a. Keep the neck stabilized

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

a. Keep the client in a side-lying position

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

b. Provide an emesis basin at the bedside c. Administer antipyretic medication d. Perform a skin assessment

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

a. Implement seizure precautions d. Turn off room lights and television e. Monitor for impaired extraocular movements

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

b. Assess for an acute hemolytic reaction

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? a. Obtain consent from the client for the transfusion b. Assess for an acute hemolytic reaction c. Explain the transfusion procedure to the client d. Obtain blood culture specimens to send to the lab

c. Take the medication at the same time every day

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

c. "I should stop eating raw clams" **Hep A is transmitted via the fecal oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish

A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? a. "I am unable to donate blood" b. "I will need to get a booster shot of immune serum globulin every year" c. "I should stop eating raw clams" d. "I can develop this disease by getting a tattoo"

b. Elevated protein

A nurse is reviewing the laboratory results of a lumbar puncture for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? a. Elevated glucose b. Elevated protein c. Presence of RBCs d. Presence of D-dimer

b. Fecal-oral contamination

A nurse is teaching a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? a. Maternal-fetal b. Fecal-oral contamination c. Genital sexual contact d. Blood to blood

a. Limit physical activity b. Avoid alcohol e. Eat small, frequent meals

A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (Select all that apply) a. Limit physical activity b. Avoid alcohol c. Take acetaminophen for comfort d. Wear a mask when in public places e. Eat small, frequent meals

d. Provide a high calorie, high carbohydrate diet

A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? a. Initiate contact precautions b. Weigh the client weekly c. Measure abdominal girth at the base of the ribcage d. Provide a high calorie, high carbohydrate diet

b. Elevate the head of the bed to 30 degrees

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to do what? a. Keep the head of the bed flat b. Elevate the head of the bed to 30 degrees c. Maintain patient on the left side with the head supported on a pillow d. Use a continuous-rotation bed to continuously change patient position

d. Obtains vital signs every 15 min throughout the procedure

A nurse preceptor is observing a new grad nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the new grad nurse indicates an understanding of the procedure? a. Inserts an 18-gauge IV catheter in the client b. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) c. Administers dextrose 5% in 0.9% NaCl IV with the infusion d. Obtains vital signs every 15 min throughout the procedure

b. Controlling fever with prescribed drugs and cooling techniques

A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is which of the following? a. Administering codeine for relief of head and neck pain b. Controlling fever with prescribed drugs and cooling techniques c. Maintaining strict bed rest with the head of the bed slightly elevated d. Keeping the room dark and quiet to minimize environmental stimulation

a. Coughing b. Sneezing d. Valsalva maneuver e. Vomiting

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? (Select all that apply) a. Coughing b. Sneezing c. Talking d. Valsalva maneuver e. Vomiting f. Keeping the head of the bed between 30- 35 degrees

d. Fecal-oral

A patient is diagnosed with Hepatitis A. The patient asks how a person can become infected with this condition. You know the most common route of transmission is which of the following? a. Blood b. Percutaneous c. Mucosal d. Fecal-oral

c. Cause vasodilation and increase the ICP **n elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg)

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will do what? a. Cause vasoconstriction and decrease the ICP b. Promote diuresis and decrease the ICP c. Cause vasodilation and increase the ICP d. Cause vasodilation and decrease the ICP

b. Mannitol will cause water and electrolyte reabsorption in the renal tubules **Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine

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

c. Restlessness

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

c. Supportive care

A patient with Hepatitis A asks you about the treatment options for this condition. Which would be the best response? a. Antiviral medications b. Interferon c. Supportive care d. Hepatitis A vaccine

c. Remove extra blankets and give the patient a cool bath **It is important to monitor the patient for hyperthermia (a fever) --> a fever increases ICP and cerebral blood volume, and metabolic needs of the patient

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

d. A normal balance among brain tissue, blood, and cerebrospinal fluid

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects which of the following? a. A severe decrease in cerebral perfusion pressure b. An alteration in the production of cerebrospinal fluid c. The loss of autoregulatory control of intracranial pressure d. A normal balance among brain tissue, blood, and cerebrospinal fluid

b. Ascites c. Splenomegaly e. Esophageal varices

A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? (Select all that apply) a. Increase albumin levels b. Ascites c. Splenomegaly d. Fluid volume deficient e. Esophageal varices

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

According to question 16, the patient's blood pressure is 130/88. What is the patient's mean arterial pressure (MAP)? a. 42 b. 74 c. 102 d. 88

c. Provide supplemental oxygen

An ER nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? a. Monitor urinary output b. Administer an osmotic diuretic c. Provide supplemental oxygen d. Initiate seizure precautions

b. Decerebrate posturing

During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as what? a. Decorticate posturing b. Decerebrate posturing c. Flaccid posturing d. Normal posturing

c. Increased ammonia level

During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? a. Decreased magnesium level b. Increased calcium level c. Increased ammonia level d. Increased creatinine level

a. Decorticate posturing d. Cheyne-stokes e. Hemiplegia f. Decerebrate posturing

Select all the signs and symptoms that occur with increased ICP. a. Decorticate posturing b. Tachycardia c. Decrease in pulse pressure d. Cheyne-stokes e. Hemiplegia f. Decerebrate posturing

b. Vasodilation of cerebral vessels d. Leaking proteins into the brain barrier **B and D are NOT compensatory mechanisms, but actions that actually increase intracranial pressure; vasoconstriction (not dilation) decreases blood flow and helps lower ICP; leaking of protein actually leads to more swelling of the brain tissue

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

a. This is a common response to feeling lack of situational control

The client hospitalized for 5 days with a medical illness says loudly, "Bring me my pain pills now!" Which initial interpretation of the client's statement should the nurse make? a. This is a common response to feeling lack of situational control b. This response by the client is inappropriate c. This indicates a problem with care delivery to the client d. This response reflects the client's feeling of anger at the self

d. Complaints of fatigue and diarrhea

The client is in the pre-icteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? a. Clay-colored stools and jaundice b. Normal appetite and pruritus c. Being afebrile and left upper quadrant pain d. Complaints of fatigue and diarrhea

c. Encephalitis **Mosquitoes, the vectors that transport encephalitis, are found in large numbers in swampy areas

The community health nurse interprets that clients who live in a swampy bayou area in the southern United States might be at risk of contracting which health problem? a. Meningitis b. Parkinson's disease c. Encephalitis d. Multiple sclerosis

d. Decreased ammonia levels

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this pt by assessing what? a. Relief of constipation b. Relief of abdominal pain c. Decreased liver enzymes d. Decreased ammonia levels

b. hepatic portal vein, high, low

The liver receives it blood supply from two sources. One of these sources is called the _________________, which is a vessel network that delivers blood _____________ in nutrients but ________ in oxygen. a. hepatic artery, low, high b. hepatic portal vein, high, low c. hepatic lobule, high, low d. hepatic vein, low, high

d. BP 190/84, HR 50, and an irregular respiratory pattern

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs? a. BP 190/84, HR 150, and an irregular respiratory pattern b. BP 80/50, HR 50, and Kussmaul respirations c. BP 80/50, HR 150, and Cheyne-Stokes respirations d. BP 190/84, HR 50, and an irregular respiratory pattern

c. Encourage family to ask questions and express feelings

The nurse has learned that there is a disruption in family dynamics after a child was hospitalized with a severe brain injury sustained in a motor vehicle crash. Which nursing intervention should have the highest priority? a. Teach the family the importance of using seatbelts b. Refer the family to support services in the community c. Encourage family to ask questions and express feelings d. Explain rules for visiting in the intensive care unit

c. Fatty stools e. Constipation and flatulence

The nurse is caring for a patient with a history of alcoholism. Which findings would indicate that the client has possibly developed chronic pancreatitis? (Select all that apply) a. Steady weight gain b. Flank pain on the left side only c. Fatty stools d. Excessive hunger e. Constipation and flatulence

a. Total parenteral nutrition b. Rest e. Positioning the patient in a fetal position f. IV fluids

The nurse is caring for a person with acute pancreatitis. Which care management strategies are appropriate for this person? (Select all that apply) a. Total parenteral nutrition b. Rest c. Oral pain medications d. Feeding via a nasogastric tube e. Positioning the patient in a fetal position f. IV fluids

a. Take all of the antibiotics as directed until completely gone

The nurse is providing instructions to the client hospitalized with bacterial meningitis who will be discharged soon. Which recommendation should have the highest priority? a. Take all of the antibiotics as directed until completely gone b. Eat a high-protein, high-calorie diet c. Exercise daily, beginning with active ROM d. Get at least 8 hours of sleep per night with frequent rest periods during the day

a. Low-protein

The nurse is reviewing the lab results for a patient with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this patient? a. Low-protein b. High-protein c. Moderate-fat d. High-carb

c. Ask the patient to extend the arms **Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread --> it is the most common and reliable sign that hepatic encephalopathy is developing

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? a. Dorsiflex the foot b. Measure abdominal girth c. Ask the patient to extend the arms d. Instruct the patient to lean forward

b. Observe and record seizure activity

The nurse observes a child starting to have a seizure. After assessing the airway, what should be the highest priority of the nurse? a. Insert an artificial airway b. Observe and record seizure activity c. Administer diazepam d. Restrain the extremities to protect the child from injury

c. A patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0 to 10 scale

The nurse on the clinical unit is assigned to 4 patients. Which patient should she assess first? a. A patient with a skull fracture whose nose is bleeding b. A patient with an acute stroke who is confused and whose daughter is present c. A patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0 to 10 scale d. A patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting

c. Decreased pulse, irregular respiration, widened pulse pressure

The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes? a. Increased pulse, irregular respiration, increased BP b. Decreased pulse, increased respiration, decreased systolic BP c. Decreased pulse, irregular respiration, widened pulse pressure d. Increased pulse, decreased respiration, widened pulse pressure

a. Prothrombin time e. Serum albumin

The nurse should evaluate the results of which lab tests while caring for a client who has cirrhosis of the liver? (Select all that apply) a. Prothrombin time b. Urinalysis c. Serum lipase d. Serum troponin e. Serum albumin

a. 90 mmHg, normal **CPP is calculated by the following formula: CPP=MAP-ICP --> the patient's CPP is 90 and this is normal

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

c. Ammonia 16 mcg/dL

The physician writes an order for the administration of Lactulose. What lab result indicates this medication was successful? a. Bilirubin <1 mg/dL b. ALT 8 U/L c. Ammonia 16 mcg/dL d. AST 10 U/L

b. Portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space **Ascites is accumulation of serious fluid in peritoneal cavity. With portal hypertension, protein shifts from the blood into the lymph. When the lymph system is unable to carry excess, it leaks thru the liver into the peritoneal cavity

The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's best response is based on the knowledge that... a. A lack of clotting factors promotes the collection of blood in the abdominal cavity b. Portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space c. Decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel d. Bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid

a. Hepatitis A

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D

b. Ingested toxins e. Fluid flowing from intravascular to extravascular space

What are causes of vasogenic cerebral edema? (Select all that apply) a. Hydrocephalus b. Ingested toxins c. Destructive lesions or trauma d. Local disruption of cell membranes e. Fluid flowing from intravascular to extravascular space

b. Crackles throughout lung fields **Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema

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

c. Hand hygiene **Hand hygiene can help prevent all types of viral hepatitis --> however, not all types of viral Hepatitis have a vaccine available

What is the BEST preventive measure to take to help prevent ALL types of viral Hepatitis? a. Vaccination b. Proper disposal of needles c. Hand hygiene d. Blood and organ donation screening

d. IV drug use

What is the MOST common transmission route of Hepatitis C? a. Blood transfusion b. Sharps injury c. Long-term dialysis d. IV drug use

a. Rest

What is the most common nursing care intervention for a person with inflammation of the liver? a. Rest b. Anti-viral medications c. Blood transfusion d. High Fat Diet

b. Change in mood or attention level

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure? a. A rising systolic blood pressure b. Change in mood or attention level c. Irregular respiratory rate and depth d. A bounding radial pulse

a. Hamstring pain when the hip and knee are flexed and then extended **Hamstring pain with hip and knee flexion and then extension is called positive Kernig sign --> this is common in intracranial hematomas

Which assessment finding in a 35-year-old client with an intracranial hematoma should concern the nurse? a. Hamstring pain when the hip and knee are flexed and then extended b. Curling of the toes when the bottom of the foot is stroked in upward motion c. Muscle aches and cramping, especially at night d. Cogwheel and lead pipe rigidity

a. Blood c. Brain tissue e. Cerebrospinal fluid (CSF)

Which components are able to change to adapt to small increases in intracranial pressure (ICP)? (Select all that apply) a. Blood b. Skull bone c. Brain tissue d. Scalp tissue e. Cerebrospinal fluid (CSF)

c. Mannitol (Osmitrol)

Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid? a. Oxygen administration b. Pentobarbital (Nembutal) c. Mannitol (Osmitrol) d. Dexamethasone (Decadron)

c. PaCO2 of 30 mm Hg e. Decreased mean arterial pressure (MAP)

Which factors decrease cerebral blood flow?(Select all that apply)? a. Increased ICP b. PaO2 of 45 mm Hg c. PaCO2 of 30 mm Hg d. Arterial blood pH of 7.3 e. Decreased mean arterial pressure (MAP)

c. Absorbing water

Which of the following is NOT a role of the liver? a. Removing hormones from the body b. Producing bile c. Absorbing water d. Producing albumin

a. Lumbar puncture

Which of the following is contraindicated in a patient with increased ICP? a. Lumbar puncture b. Midline position of the head c. Hyperosmotic diuretics d. Barbiturates medications

a. High complex carbohydrates for energy b. Reading food labels d. Small, frequent meals e. Lean proteins

Which of the following should be included in diet teaching for a person with end stage liver cirrhosis? (Select all that apply) a. High complex carbohydrates for energy b. Reading food labels c. High fat diet d. Small, frequent meals e. Lean proteins

b. A patient who is admitted with a traumatic brain injury

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

c. BP 200/60, HR 50, RR 8 **There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea

Which patient below with ICP is experiencing Cushing's Triad? a. BP 150/112, HR 110, RR 8 b. BP 90/60, HR 80, RR 22 c. BP 200/60, HR 50, RR 8 d. BP 80/40, HR 49, RR 12

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

While positioning a patient in bed with increased ICP, it important to avoid which of the following? a. Midline positioning of the head b. Placing the HOB at 30-35 degrees c. Preventing flexion of the neck d. Flexion of the hips

a. To quickly assess the patient's LOC

Why is the Glasgow Coma Scale (GCS) used? a. To quickly assess the patient's LOC b. To assess the patient's ability to communicate c. To assess the patient's ability to respond to commands d. To assess the patient's coordination with motor responses

b. Dark brown urine c. Yellowing of the sclera e. Jaundice of the skin

You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? (Select all that apply) a. Frothy light-colored urine b. Dark brown urine c. Yellowing of the sclera d. Dark brown stool e. Jaundice of the skin f. Bluish mucous membranes

a. Excessive coughing d. Alcohol consumption e. Straining during a bowel movement f. Vomiting

You're providing an in-service to new nurse graduates about esophageal varices in patients with cirrhosis. You ask the graduates to list activities that should be avoided by a patient with this condition. Which activities listed are correct? (Select all that apply) a. Excessive coughing b. Sleeping on the back c. Drinking juice d. Alcohol consumption e. Straining during a bowel movement f. Vomiting

b. 60-100 mmHg

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

a. Thrombocytopenia c. Increased PT/INR d. Leukopenia

Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? (Select all that apply) a. Thrombocytopenia b. Vision changes c. Increased PT/INR d. Leukopenia