Complex Study Questions

The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis? a. Glasgow Coma Scale score of 3 b. Train-of-four yields two twitches c. Bispectral index of 60 d. CAM-ICU positive

ANS: B A train-of-four response of two twitches (out of four) using a peripheral nerve stimulator indicates adequate paralysis. The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness. The bispectral index provides an assessment of sedation. The CAM-ICU is a tool to assess delirium.

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.

ANS: B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient's airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurse's first action should be to a. measure abdominal girth to determine the amount of fluid accumulation. b. position the patient in a semi-Fowler's position. c. prepare the patient for emergent paracentesis. d. administer diuretics.

ANS: B Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowler's position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowler's position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.

The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitor (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely to be secondary to a. infection with Helicobacter pylori bacteria. b. decreased acetylcholine production. c. a decreased number of parietal cells. d. ischemia associated with sepsis.

ANS: D A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Ischemia is the prior etiology associated with stress ulcer formation. Ischemic ulcers develop within hours of an event such as hemorrhage, multisystem trauma, severe burns, heart failure, or sepsis. The shock, anoxia, and sympathetic responses decrease mucosal blood flow, leading to ischemia. The secretion of acid is important in the pathogenesis of ulcer disease. Acetylcholine (a neurotransmitter), gastrin (a hormone), and secretin (a hormone) stimulate the chief cells, which stimulate acid secretion. Parietal cell mass in people with peptic ulcer disease is 1.5 to 2 times greater than in persons without disease. Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers.

The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse a. should suggest that the patient receive epidural analgesia. b. provides oral pain medication on an "as needed" (PRN) basis. c. removes any nasogastric tubes. d. administers pain medication on a routine schedule.

ANS: D Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the form of a patient-controlled analgesia (PCA) pump. In the case in which a PCA pump is not ordered, pain medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.

When assessing bowel sounds, the nurse a. uses the "bell" part of the stethoscope. b. listens at least 15 minutes. c. Expect bowel sounds to be regular in rhythm. d. listens for 5 minutes before noting "absent bowel sounds."

ANS: D Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made.

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patient's general orientation. c. Determine the patient's drug allergies. d. Determine the time of symptom onset.

ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.

ANS: D In this scenario, the patient's temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the provider of the patient's blood pressure.

ANS: B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system, can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distension. Other causes that should be ruled out before pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow, deep breaths will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the provider.

The nurse is to assist the provider in performing bedside endoscopy on a patient. To prevent respiratory complications, the nurse places the patient a. supine in Trendelenburg position. b. in a left lateral reverse Trendelenburg position. c. flat with the feet elevated. d. in a semi-Fowler's position.

ANS: B Because endoscopy is performed at the patient's bedside, the nurse assists with procedures and monitors for untoward effects. Maintenance of airway and breathing during endoscopic procedures is of major concern. Placement of the patient in a left lateral reverse Trendelenburg position helps to prevent respiratory complications.

The nurse is caring for a patient with liver disease. When assessing the patient's laboratory values, the nurse should a. disregard the level of conjugated bilirubin. b. assess the total bilirubin c. call the provider immediately if the direct bilirubin is elevated. d. be aware that unconjugated bilirubin is harmless.

ANS: B Bilirubin enters the circulation bound to albumin and is unconjugated. This portion of the bilirubin is reflected in the indirect serum bilirubin level. In the liver, bilirubin is conjugated with glucuronic acid. Conjugated bilirubin is soluble and excreted in bile. Cirrhosis and liver cancer decrease the liver's ability to conjugate bilirubin. Some conjugated bilirubin returns to the blood and is reflected in the direct serum bilirubin level. The direct or conjugated bilirubin is increased in liver failure. Total bilirubin is also measured and will also be increased in liver failure. There is no need to call the provider for values only slightly elevated. Unconjugated bilirubin is toxic to cells.

The nurse is assessing the patient's pain using the Critical Care Pain Observation Tool. Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention? a. Absence of vocal sounds b. Fighting the ventilator c. Moving legs in bed d. Relaxed muscles in upper extremities

ANS: B Fighting the ventilator is rated with the greatest number of points for compliance with the ventilator, and could indicate pain or anxiety. Absence of vocal sounds (e.g., no crying) and relaxed muscles do not indicate pain and are not given a point value. The patient may be moving the legs as a method of range of motion, not necessarily in response to pain. The patient needs to be assessed for restlessness if the movement is excessive.

The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should a. evaluate the patient for symptoms of constipation. b. observe for diarrhea. c. assess mucous membranes for signs of dryness. d. expect decreased bowel sounds.

ANS: B Functions of the GI system are influenced by neural and hormonal factors. Parasympathetic cholinergic fibers, or drugs that mimic parasympathetic effects, stimulate GI secretion and motility.

The patient is admitted with the diagnosis of GI bleeding. The patient's heart rate is 140 beats per minute, and the blood pressure is 84/44 mm Hg. These values may indicate: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. c. increased blood flow to the skin, lungs, and liver.

ANS: B Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.

The nurse wishes to assess the quality of a patient's pain. Which of the following questions is appropriate to obtain this assessment if the patient is able to give a verbal response? a. "Is the pain constant or intermittent?" b. "Is the pain sharp, dull, or crushing?" c. "What makes the pain better? Worse?" d. "When did the pain start?"

ANS: B If the patient can describe the pain, the nurse can assess quality, such as sharp, dull, or crushing. The other responses relate to continuous or intermittent presence, what provides relief, and duration.

Lactulose is considered the first-line treatment for hepatic encephalopathy and works by a. causing ammonia to enter the bloodstream via the colon. b. trapping ammonia in the bowel for excretion. c. causing constipation and inhibiting the excretion of ammonia. d. creating an alkaline environment in the bowel.

ANS: B Lactulose is considered the first-line treatment for hepatic encephalopathy. Lactulose creates an acidic environment in the bowel that causes the ammonia to leave the bloodstream and enter the colon. Ammonia is trapped in the bowel. Lactulose also has a laxative effect that allows for elimination of the ammonia. Lactulose is given orally or via a rectal enema.

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper handwashing.

ANS: B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority. Hand washing is important for all patients. There is no indication the patient has temperature alterations. Padding bony prominences may or may not be needed.

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. The baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the provider of the BP. d. Begin weaning the infusion.

ANS: B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient's blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the provider of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.

The patient is diagnosed with hepatitis. In caring for this patient, the nurse should a. administer anti-inflammatory medications. b. provide rest, nutrition, and antiemetics if needed. c. provide antianxiety medications freely to decrease agitation. d. instruct the patient to take over-the-counter anti-inflammatory medications at home.

ANS: B No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.

The patient is admitted for GI bleeding, but the source is unknown. Before ordering endoscopy, the provider orders octreotide to be given intravenously. The purpose of this medication is to a. increase portal pressure and improve liver function. b. decrease splanchnic blood flow and portal pressure. c. vasodilate the splanchnic arteriolar bed. d. increase blood flow in the liver's collateral circulation.

ANS: B Octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow, reduce portal pressure, and have minimal adverse effects Octreotide does not increase portal pressure, vasodilate the splanchnic arteriolar bed, or increase blood flow in the liver's collateral circulation.

The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient a. has a 99% chance of survival. b. has a 15% chance of dying. c. has a 40% chance of dying. d. has no chance of survival.

ANS: B Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient's chance of significant morbidity and mortality. In Ranson's research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

The nurse is assessing the patient and notices that the oral cavity is only slightly moist and contains a scant amount of thick saliva even though the patient's fluid intake has been sufficient. The nurses realizes that the condition of the patient's mouth is probably caused by a. thoughts of food. b. sympathetic nerve stimulation. c. overstimulation of the sublingual glands. d. parasympathetic nerve stimulation.

ANS: B Saliva is the major secretion of the oropharynx and is produced by three pairs of salivary glands: submaxillary, sublingual, and parotid. Stimuli such as sight, smell, thoughts, and taste of food stimulate salivary gland secretion. Parasympathetic stimulation promotes a copious secretion of watery saliva. Conversely, sympathetic stimulation produces a scant output of thick saliva. The normal daily secretion of saliva is 1200 mL.

The provider prescribes fosphenytoin, 1.5 g intravenous (IV) loading dose, for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer the drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

ANS: B The nurse can administer the medication over 10 minutes as prescribed (100 to 150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose prescribed is appropriate for the patient's weight. Fosphenytoin does not have to be administered with normal saline or via a central line.

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which prescription by the provider should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam. c. Obtain stat portable chest x-ray. d. Administer phenytoin.

ANS: B The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticus. Phenytoin is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to: a. give medications that will suppress the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. c. teach the patient that the submucosa is the innermost part of the gut wall. d. give medications intravenously because the submucosa has no blood vessels.

ANS: B The second layer of the gut wall, the submucosa, is composed of connective tissue, blood vessels, and nerve fibers. Beneath the mucosa, submucosa, and muscular layer are various nerve plexuses that are innervated by the autonomic nervous system. Disturbances in these neurons in a given segment of the GI tract cause a lack of motility. Therapies innervating the autonomic nervous system are thus appropriate. The muscular layer is the major layer of the wall. The serosa is the outermost layer.

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the provider prescriptions, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push

ANS: B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.

The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Administer over 20 to 30 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

ANS: B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Phenytoin should be administered over 20 to 30 minutes. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario.

The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.) a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs. d. antacids. e. cholinergic drugs.

ANS: B, C, D Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.

Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.) a. Obstructed portal circulation b. Dilated vessels c. Tortuous vessels d. Constricted vessels e. Presence of an abscess

ANS: B, C, D Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate infection, abscess, or tumor.

The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) a. Hypoglycemia b. Malnutrition c. Ascites d. Hypercoagulation e. Disseminated intravascular coagulation

ANS: B, C, E Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop

The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss? a. all vital signs would expect to be normal. b. Oral temperature of 103°. c. Heart rate 125 beats per minute. d. Systolic blood pressure of 120 mm Hg.

ANS: C As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume.

The nurse is caring for a patient admitted with bacterial meningitis. Vital signsassessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5°F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bed rest at all times.

ANS: C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation, such as photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bed rest are all appropriate nursing interventions but are not the priorities in this scenario.

The nurse is assessing a patient admitted with pancreatitis. In doing so, the nurse a. palpates the pancreas for size and shape. b. emphasizes to the patient that pancreatic inflammation does not spread. c. assesses symptoms that could indicate involvement of the stomach. d. explains to the patient that back pain is not a sign of pancreatitis.

ANS: C Because the pancreas lies retroperitoneally, it cannot be palpated; this characteristic explains why diseases of the pancreas can cause pain that radiates to the back. In addition, a well-developed pancreatic capsule does not exist, and this may explain why inflammatory processes of the pancreas can spread freely and affect the surrounding organs (stomach and duodenum).

When assessing the patient's bowel sounds, the nurse a. listens to the abdomen after palpation is done. b. places the patient in a relaxed prone position. c. listens to bowel sounds before palpation. d. places a pillow over the patient's knees.

ANS: C Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract. Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is performed before auscultation is begun. A supine position with the patient's arms at the sides or folded at the chest is usually recommended. Placing a pillow under the patient's knees also helps to relax the abdominal wall.

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? 54 mm Hg 72 mm Hg 90 mm Hg 126 mm Hg

ANS: C CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first? a. Blood cultures (2 specimens) for temperature >101°F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours

ANS: C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

ANS: C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume.To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.

The nurse is caring for four patients on the progressive care unit. Which patient is at greatest risk for developing delirium? a. 36-year-old recovering from a motor vehicle crash; being treated with an evidence-based alcohol withdrawal protocol. b. 54-year-old postoperative aortic aneurysm resection with a 40 pack-year history of smoking c. 86-year-old from nursing home with dementia, postoperative from colon resection, still being mechanically ventilated d. 95-year-old with community-acquired pneumonia; family has brought in eyeglasses and hearing aid

ANS: C From this list, the 86-year-old postoperative nursing home resident is at greatest risk due to advanced age, cognitive impairment, and some degree of respiratory failure. The 96-year-old has been provided eyeglasses and a hearing aid, which will decrease the risk of delirium.

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? - Have the patient blow the nose until clear. - Insert bilateral cotton nasal packing. - Place a nasal drip pad under the nose. - Suction the left nares until the drainage clears.

ANS: C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse a. watches the patient for diarrhea. b. evaluates renal function daily. c. assesses the patient for epigastric discomfort. d. instructs the patient that this medication must be taken for 2 weeks.

ANS: C Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment.

The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the lab work a few hours later. The new hemoglobin and hematocrit would be expected to be a. hemoglobin 7.5 g/dL and hematocrit 25%. b. hemoglobin 9.5 g/dL and hematocrit 29%. c. hemoglobin 10.5 g/dL and hematocrit 32%. d. hemoglobin 12.5 g/dL and hematocrit 36%.

ANS: C One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%, but this effect is influenced by the patient's intravascular volume status and whether the patient is actively bleeding.

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

ANS: C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35 to 45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.

The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. The nurse should a. cut the gastric balloon lumen and watch for improved symptoms. b. cut the esophageal lumen and watch for improvement. c. cut all three lumens and remove the tube. d. call the provider with an update of the patient's condition.

ANS: C Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible life-threatening complications that need to be assessed. Esophageal rupture may also occur and is characterized by the abrupt onset of severe pain. In the event of any of these life-threatening emergencies, all three lumens are cut and the entire tube is removed. For this reason, scissors are kept at the patient's bedside at all times. Endotracheal intubation is strongly recommended to protect the airway.

The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that a. surgery for pseudocysts must be done immediately. b. a cholecystectomy is usually done when pseudocysts are found. c. pseudocysts may resolve spontaneously, so surgery may be delayed. d. pseudocysts require pancreatic resection, removing the entire pancreas.

ANS: C Surgery may be indicated for pseudocysts; however, it is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed. Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peritonitis.

Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they a. can be used only on heavily sedated patients. b. can be used only on pediatric patients. c. provide raw EEG data and a numeric value. d. require only five leads.

ANS: C The BIS and PSI have very simple steps for application, and results are displayed as raw EEG data and the numeric value. A single electrode is placed across the patient's forehead and is attached to a monitor. These monitors can be used in both children and adults and in patients with varying levels of sedation.

The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse recognizes __________ as indicating the greatest level of pain. a. brow lowering b. eyelid closing c. grimacing d. relaxed facial expression

ANS: C The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to assessment of facial grimacing.

The provider has opted to treat a patient with a complete spinal cord injury with Solumedrol. The provider orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hr for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg

ANS: C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg 70 kg) + (5.4 mg 70 kg) 23 hours = 10,794 mg.

The nurse is caring for a patient with hyperactive delirium. The nurse focuses interventions toward keeping the patient: a. comfortable. b. nourished. c. safe. d. sedated.

ANS: C The greatest priority in managing delirium is to keep the patient safe. Sedation may contribute to the development of delirium. Comfort and nutrition are important, but they are not priorities.

The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that a. the hematocrit is a direct reflection of quick blood loss. b. as extravascular fluid enters the vascular space, the hematocrit increases. c. the hematocrit value does not change substantially during the first few hours. d. the administration of intravenous fluids has no effect on hematocrit levels.

ANS: C The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated by fluids and blood products that are administered during the resuscitation period.

The liver plays a major role in homeostasis by a. synthesizing factor I but not factor II. b. synthesizing clotting factors without the need for vitamin K. c. removing active clotting factors from the circulation. d. synthesizing factor II but not factor I.

ANS: C The liver synthesizes fibrinogen (factor I); prothrombin (factor II); and factors VII, IX, and X. Vitamin K is essential for the synthesis of other clotting factors. The liver also removes active clotting factors from the circulation and therefore prevents clotting in the macrovascular and microvascular.

The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should answer: a. "Pancreatitis is extremely rare, and no one knows why it causes pain." b. "Pancreatitis is caused by diabetes; you should be checked." c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." d. "The pain is localized to the pancreas. Fortunately, it will not affect anything else."

ANS: C The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.

The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse a. observes for skin pigmentation and discolorations. b. looks for pulsations originating from the vena cava. c. has the patient take a deep breath. d. watches for signs of pain and distension.

ANS: C The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration. Pulsations, if they are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and hydration status, not masses. Abdominal distension, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity.

The nurse is preparing to administer a routine dose of phenytoin. The provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer for over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the provider. d. Assess cardiac rhythm.

ANS: C The ordered dose is an inappropriate maintenance dose. The nurse should contact the provider. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia (PCA)? a. Patient with a C4 fracture and quadriplegia b. Patient with a femur fracture and closed head injury c. Postoperative patient who had elective bariatric surgery d. Postoperative cardiac surgery patient with mild dementia

ANS: C The patient undergoing bariatric surgery (an elective procedure) is the best candidate for PCA as this patient should be awake, cognitively intact, and will have the acute pain related to the surgical procedure. The quadriplegic would be unable to operate the PCA pump. The cardiac surgery patient with mild dementia may not understand how to operate the pump. Likewise, the patient with the closed head injury may not be cognitively intact.

The primary mode of action for neuromuscular blocking agents used in the management of some ventilated patients is a. analgesia. b. anticonvulsant therapy. c. paralysis. d. sedation.

ANS: C These agents cause respiratory muscle paralysis. They do not provide analgesia or sedation. They do not have anticonvulsant properties.

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.

ANS: C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse's first priority is to a. administer antianxiety medications as ordered. b. administer pain medication as ordered. c. identify and treat the underlying cause. d. reassess the patient hourly to determine whether symptoms resolve on their own.

ANS: C When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat the underlying cause, which could be hypoxemia, hypoglycemia, hypotension, pain, or withdrawal from alcohol and drugs. Treatment is not initiated until assessment is completed. Medication may not be needed if the underlying cause can be resolved.

Nonpharmacological approaches to pain and/or anxiety that may best meet the needs of critically ill patients include: (Select all that apply.) a. anaerobic exercise. b. art therapy. c. guided imagery. d. music therapy. e. animal therapy.

ANS: C, D, E Guided imagery is a powerful technique for controlling pain and anxiety, especially that associated with painful procedures. Similar to guided imagery, a music therapy program offers patients a diversionary technique for pain and anxiety relief. Likewise animal therapy has many benefits for the critically ill patient. Anaerobic exercise is not a nonpharmacological approach for managing pain and anxiety. Most critically ill patients are not able to participate in art therapy.

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device "prn" c. Recording ICP as a "mean" value d. Use of a pressurized flush system e. Zero referencing the transducer system

ANS: C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Monro. Manually flushing the device may result in an increase in ICP.

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low.

ANS: CThe ICP is above the normal level of 0 to 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patient's airway patency. b. Elevate the head of the patient's bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.

ANS: A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient's airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority.

The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that a. Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. b. this type of bleeding is treated by giving chewable aspirin. c. the bleeding, although impressive, is self-limiting with little actual blood loss. d. it is not usually associated with alcohol intake or retching.

ANS: A A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal anti-inflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair.

Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal cord injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to a. rule out massive upper GI bleeding. b. detect the presence of melena in the stomach. c. visually determine the presence of occult bleeding. d. obtain samples for guaiac to confirm current bleeding.

ANS: A Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool with a chemical reagent (guaiac).

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports before use. d. Dispose of all bloody dressings in biohazard bags.

ANS: A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing of all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

The liver detoxifies the blood by a. converting fat-soluble compounds to water-soluble compounds. b. converting water-soluble compounds to fat-soluble compounds. c. excreting fat-soluble compounds in feces. d. metabolizing inactive toxic substances to active forms.

ANS: A Drugs, hormones, and other toxic substances are metabolized by the liver into inactive forms for excretion. This process is usually accomplished by conversion of the fat-soluble compounds to water-soluble compounds. They can then be excreted via the bile or the urine.

.The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

ANS: A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

The patient is admitted with generalized fatigue and low hemoglobin and hematocrit levels. The patient denies vomiting and states that the last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patient's next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.

ANS: A GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac). Stool and nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black, foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting or drainage from a nasogastric tube that yields blood or coffee-ground-like material is associated with upper GI bleeding. However, blood or coffee-ground-like contents may not be present if bleeding has ceased or if it arises beyond a closed pylorus.

The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen? a. Creatinine: 3.1 mg/dL b. Platelet count 350,000 billion/L c. White blood count 13, 550 mm3 d. ALT 25 U/L

ANS: A Ibuprofen can result in renal insufficiency, which may be noted in an elevated serum creatinine level. Thrombocytopenia (low platelet count) is another possible side effect. This platelet count is elevated. An elevated white blood count indicates infection. Although ibuprofen is cleared primarily by the kidneys, it is also important to assess liver function, which would show elevated liver enzymes, not low values such as shown here.

The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should a. monitor the patient's blood pressure and evaluate for signs of dehydration. b. restrict intravenous and oral fluid intake because of fluid shifts. c. avoid the use of colloid IV solutions in managing the patient's fluid status. only use crystalloid fluids to prevent IV lines from clotting.

ANS: A In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity. Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of acute pancreatitis. The IV solutions ordered for fluid resuscitation are usually colloids or lactated Ringer's solution; however, fresh frozen plasma and albumin may also be used. IV fluid administration with crystalloids at 500 mL/hr is at times required to maintain hemodynamic status. Often, vigorous IV fluid replacement at 250 to 300mL/hr continues for the first 48 hours or a volume adequate to maintain a urine output of greater than or equal to 0.5 mL/kg body weight per hour. Fluid replacement helps to maintain perfusion to the pancreas and kidneys, reducing the potential for complications.

Infection by Helicobacter pylori bacteria is a major cause of a. duodenal ulcers. b. Cushing's ulcers. c. Curling's ulcers. d. stress ulcers.

ANS: A Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that develop as a result of burn injury are often called Curling's ulcers. Stress ulcers associated with severe head trauma or brain surgery are called Cushing's ulcers.

The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse a. evaluate renal function studies daily. b. give the medication every 12 hours. c. evaluate liver studies for signs of neomycin-induced damage. d. obtain stool guaiac tests to ensure that pathogens are being destroyed.

ANS: A Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to the kidneys (not liver) and therefore cannot be given to patients with renal failure. Daily renal function studies are monitored when neomycin is administered. Guaiac tests are used to detect occult bleeding.

The most important nursing intervention for patients who receive neuromuscular blocking agents is to a. administer sedatives in conjunction with the neuromuscular blocking agents. b. assess neurological status every 30 minutes. c. avoid interaction with the patient, because he or she won't be able to hear. d. restrain the patient to avoid self-extubation.

ANS: A Neuromuscular blocking agents cause paralysis only; they do not cause sedation. Therefore, concomitant administration of sedatives is essential. Neurological status is monitored according to unit protocol. Nurses should communicate with all critically ill patients, regardless of their status. If the patient is paralyzed, restraining devices may not be needed.

Nociceptors differ from other nerve receptors in the body in that they: a. adapt very little to continual pain response. b. inhibit the infiltration of neutrophils and eosinophils. c. play no role in the inflammatory response. d. transmit only the thermal stimuli.

ANS: A Nociceptors are stimulated by mechanical, chemical, or thermal stimuli. Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response. The body continues to experience pain until the stimulus is discontinued or therapy is initiated. This is a protective mechanism so that the body tissues being damaged will be removed from harm. Nociceptors usually initiate inflammatory responses near injured capillaries. As such, the response promotes infiltration of injured tissues with neutrophils and eosinophils.

The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an extended period. Which of the following nursing interventions would improve the patient's well-being and reduce anxiety the most? a. Arrange for the patient's dog to be brought into the unit (per protocol). b. Provide aromatherapy with scents such as lavender that are known to help anxiety. c. Secure the harpist to come and play soothing music for an hour every afternoon. d. Wheel the patient out near the unit aquarium to observe the tropical fish.

ANS: A Nonpharmacological approaches are helpful in reducing stress and anxiety, and each of these activities has the potential for improving the patient's well-being. The patient is likely to benefit most from the presence of his or her own dog rather than the other activities, however; if unit protocol does not allow the patient's own dog, the nurse should investigate the use of therapy animals or the other options.

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? 1) Frequent neurological assessments 2) Side to side position changes 3) Range-of-motion to extremities 4) Frequent oropharyngeal suctioning

ANS: A Nurses complete neurological assessments based on prescribed frequency and the severity of the patient's condition. The newly admitted patient has an altered neurological status, so frequent neurological assessments are most important to include in the patient's plan of care. Side to side position changes, range-of-motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient's plan of care, but in the setting of increased intracranial pressure they should not be regularly performed unless indicated.

Pain control is a nursing priority in patients with acute pancreatitis because pain a. increases pancreatic secretions. b. is caused by decreased distension of the pancreatic capsule. c. decreases the patient's metabolism. d. is caused by dilation of the biliary system.

ANS: A Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patient's metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distension of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.

The nurse is caring for a patient with severe pancreatitis who is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and a. places the patient on seizure precautions. b. expects that the provider will come and remove the endotracheal tube. c. withholds any further calcium treatments. d. places an oral airway at the bedside.

ANS: A Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low, and replacement of calcium is expected.

The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that the pain has become extreme. The nurse notes that the patient's abdomen is rigid. The nurse should a. call the provider immediately. b. give the patient pain medication. c. remove the NG tube. d. give the patient an antacid.

ANS: A Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine blockers may or may not be indicated, depending on the cause of the upper GI bleeding. Mortality rates for patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the time of surgery; therefore, it is essential that the provider be called immediately.

The nurse is caring for a critically ill patient with end-stage liver disease. The nurse knows that the patient is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a hyperdynamic status? a. Jugular venous distension b. Normal sinus rhythm on the cardiac monitor c. Blood pressure of 180/90 mm Hg d. Stools that are guaiac positive

ANS: A Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distension, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases, and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.

A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse's commands. The nurse should: a. assess the patient's level of pain. b. decrease the ventilator rate. c. provide sedation as ordered. d. suction the patient again.

ANS: A Pulse, respirations, and blood pressure frequently result from activation of the sympathetic nervous system by the pain stimulus. Because the patient is postoperative, the patient should be assessed for the presence of pain and need for pain medication. Decreasing the ventilator rate will not help in this situation. Providing sedation may calm the patient but will not solve the problem if the physiological changes are from pain. The patient has just been suctioned and the airway is clear. There is no need to suction again.

The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following? a. Assess for signs of peptic ulcer. b. Be watchful for increased saliva production. c. Evaluate for a decrease in potassium level. d. Give the patient medications to prevent anemia.

ANS: A Secretion of mucus by Brunner's glands is inhibited by sympathetic stimulation, which leaves the duodenum unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract is the site for more than 50% of peptic ulcers. Sympathetic stimulation produces a scant output of thick saliva. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia. However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium, potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk for fluid and electrolyte imbalances and acid-base disturbances. However, nothing indicates that the patient is vomiting or has GI suction.

The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administera. a. H2-histamine receptor blockers. b. gastrin. c. vagal stimulation. d. vitamin B12.

ANS: A Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid. Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine and therefore hydrochloric acid stimulation. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia but has no effect on ulcer formation. Gastrin is a hormone that stimulates acid. The vagus nerve helps digestion; however, vagal stimulation is not a treatment for peptic ulcer disease.

The nurse receives a patient from the emergency department following a closed head injury. After insertion of a ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous

ANS: A The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient's mouth and insert a padded tongue blade. d. Restrain the patient's extremities until the seizure subsides.

ANS: A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient's jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care.

The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and tetracycline but is not responding. The nurse expects that a. bismuth will be added to the current triple therapy. b. a 6-day course of levofloxacin may be used. c. a second-line therapy is not usually effective. d. the proton pump inhibitor will be changed to a higher dose.

ANS: A Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth, metronidazole, and a tetracycline. A 10-day course of levofloxacin may also be administered as a second-line therapy for H. pylori infections.

After gastric bypass surgery, the patient is getting vitamin B12 injections. The patient asks about the purpose of this vitamin. The nurse explains that a. vitamin B12 is needed for the formation of red blood cells. b. vitamin B12 is needed to prevent a type of anemia. c. vitamin B12 is essential for surgical wound healing. d. vitamin B12 is always deficient in obese people.

ANS: A Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach. Vitamin B12 is essential in the formation of red blood cells. A deficiency of B12 does lead to anemia, but this answer is not as specific as stating the relationship of B12 to red blood cells, so it is not as informative. Vitamins A and C are more essential for wound healing. Obese people may or may not be deficient in this vitamin.

Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.) a. Inability to communicate b. Invasive procedures c. Monitoring devices d. Nursing care e. Preexisting conditions

ANS: A, B, C, D, E All of these factors predispose the patient to pain or anxiety.

Factors in the critical care unit that may predispose the client to increased pain and anxiety include: (Select all that apply.) a. an endotracheal tube. b. frequent vital signs. c. monitor alarms. d. room temperature. e. hostile environment.

ANS: A, B, C, D, E Anxiety is likely to result from loss of control, the inability to communicate, continuous noise and lighting, excessive stimulation (including repeated vital sign measurements), lack of mobility, and uncomfortable room temperatures. Increased anxiety levels often lead to increased pain perception. Environments that are perceived as hostile also contribute.

Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.) a. Environmental manipulation b. Explanations of monitoring equipment c. Guided imagery d. Music therapy e. Provision of personal items

ANS: A, B, C, D, E Manipulating the environment so that it appears less hostile helps decrease anxiety, as does continually reorienting the patient. Focus techniques such as guided imagery and music therapy can create a state of relaxation. Personal items can reduce anxiety and provide a pleasant distraction.

In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. The presence of cervical injuries is a contraindication to the assessment of this reflex.

ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.

In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be hampered by which of the following? (Select all that apply.) a. Administration of neuromuscular blocking agents b. Delirium c. Effective nurse communication and assessment skills d. Nonverbal patients e. Ventilated patient

ANS: A, B, D Delirium appears in approximately 80% of patients in the intensive care unit. Delirium is characterized by changing mental status, inattention, disorganized thinking, and altered levels of consciousness. Patients in the intensive care unit may not be able to verbalize because of the presence of an artificial airway, sedative medication, neuromuscular blocking agents, or brain injury. Effective nurse-to-patient communication and assessment skills would facilitate assessment of pain and anxiety. There are tools and assessment methods to assess pain in ventilated patients.

The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all that apply.) a. is a safe and effective method for administering analgesia. b. has potentially fewer side effects than other routes of analgesic administration. c. is an ideal method to provide most critically ill patients some control over their treatment. d. provides good quality analgesia. e. does not work well without family assistance.

ANS: A, B, D PCA is safe and effective, provides good-quality analgesia, and has potentially fewer side effects than other routes. PCA management is rarely appropriate for critically ill patients because most patients are unable to depress the button, or they are too ill to manage their pain effectively. If the patient is cognitively intact, family assistance is not needed to use this modality and is not advisable; the patient needs to be able to push the button.

Choose the items that are common to both pain and anxiety. (Select all that apply.) a. Cyclical exacerbation of one another b. Require good nursing assessment for proper treatment c. Response only to real phenomena d. Subjective in nature e. Perception may be influenced by prior experience

ANS: A, B, D, E Both pain and anxiety are subjective in nature. One can exacerbate the other in a vicious cycle that often requires good nursing assessment to manage the precipitating problem and break the cycle. Anxiety is a response to a real or perceived fear. Pain is a response to real or "phantom" phenomenon but always involves transmission of nerve impulses. Both relate to the patient's perceptions of pain and fear. Previous experiences of both pain and/or anxiety can influence the patient's perception of both. Anxiety is a response to real or perceived fear, and pain is a response to a real or "phantom" phenomenon.

Anxiety differs from pain in that: (Select all that apply.) a. it is confined to neurological processes in the brain. b. it is linked to reward and punishment centers in the limbic system. c. it is subjective. d. there is no actual tissue injury. e. it can be increased by noise and light.

ANS: A, B, D, E Unlike pain, anxiety is linked to the reward and punishment centers in the limbic system of the brain. It is totally neurological and does not involve tissue injury. Like pain, it is a subjective phenomenon. Noise, light, and other stimuli can increase the intensity of anxiety. Both anxiety and pain are subjective in nature.

When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) a. Severity of blood loss b. Hemodynamic stability c. Vital signs every 30 minutes d. Signs of hypervolemic shock e. Necessity for fluid resuscitation

ANS: A, B, E Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.

Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. withholding analgesics that could mask abdominal discomfort. d. stimulating gastric content motility into the duodenum. e. utilizing supportive therapies aimed at decreasing gastrin release.

ANS: A, B, E Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.

ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

In the healthy individual, pain and anxiety: (Select all that apply.) a. activate the sympathetic nervous system (SNS). b. decrease stress levels. c. help remove one from harm. d. increase performance levels. e. limit sympathetic nervous system activity.

ANS: A, C, D In the healthy person, pain and anxiety are adaptive mechanisms used to increase performance levels or to remove one from potential harm. The "fight or flight" response occurs in response to pain and/or anxiety and involves the activation of the sympathetic nervous system. Pain and anxiety, however, can induce significant stress. The SNS is activated, not limited, by pain and/or anxiety.

Which of the following statements regarding pain and anxiety are true? (Select all that apply.) a. Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal. b. Critically ill patients often experience anxiety, but they rarely experience pain. c. Pain and anxiety are often interrelated and may be difficult to differentiate because their physiological and behavioral manifestations are similar. d. Pain is defined by each patient; it is whatever the person experiencing the pain says it is. e. While anxiety is unpleasant, it does not contribute to mortality or morbidity of the critically ill patient.

ANS: A, C, D Pain is defined by each patient, anxiety is associated with marked apprehension, and pain and anxiety are often interrelated. Critically ill patients commonly have both pain and anxiety. Anxiety does increase both morbidity and mortality in critically ill patients, especially those with cardiovascular disease.

A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.) a. administration of sedatives concurrently with neuromuscular blockade. b. dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c. ensuring that deep vein thrombosis prophylaxis is initiated. d. providing interventions for eye care, oral care, and skin care. e. ensuring good nutrition with frequent feedings throughout the day.

ANS: A, C, D Pancuronium is a neuromuscular blocking agent (NMB) resulting in complete paralysis of the patient. Patients receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise is most appropriate. Feeding the patient on an NMB orally is not possible.

The nurse is assessing the critically ill patient for delirium. The nurse recognizes which characteristics that indicate hyperactive delirium? (Select all that apply.) a. Agitation b. Apathy c. Bitingd. d. Hittinge. e. Restlessness

ANS: A, C, D, E All except for apathy are characteristics of hyperactive delirium. Apathy is seen in hypoactive cases.

The nurse is caring for a patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is responsive, the nurse is not able to read the patient's lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nurse to use when assessing the patient's pain level? (Select all that apply.) a. The FACES scale b. Pain Intensity Scale c. The PQRST method d. The Visual Analogue Scale e. The CAM tool

ANS: A, D The PQRST method and the Pain Intensity Scale require verbalization and/or writing to communicate pain level. The FACES scale and the Visual Analogue Scale can be used by simply having the patient point to the appropriate place. Because of this, they are the easiest to use with children, people with language barriers, and intubated patients. The CAM tool is used to assess delirium.

The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must a. maintain as little traction as possible. b. apply external traction using a side rail of the bed. c. deflate the gastric balloon before the esophageal balloon. d. deflate the esophageal balloon before the gastric balloon.

ANS: D It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached to a helmet or to the foot of the bed (not the side rail). Proper amounts of traction are essential because too little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.

The patient is ordered to have large-volume gastric lavage. The nurse will most likely need to a. insert a small-bore nasogastric tube. b. use 2 to 4 liters of room-temperature normal saline. c. remove the nasogastric tube before lavage is started. d. insert a large-bore nasogastric tube.

ANS: D Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction. If lavage is ordered, 1 to 2 liters of room-temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric tube may be left in or removed.

Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that a. patients with pancreatitis must eat nothing in order to prevent release of secretin. b. nasogastric suction is essential in treating patients with pancreatitis. c. a nasogastric tube is no longer required to treat patients with ileus. d. immediate oral feeding in patients with mild pancreatitis may help recovery.

ANS: D Nasogastric suction and "nothing by mouth" status were classic treatments for patients with acute pancreatitis to suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally, secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum; therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric distension, and a decreased level of consciousness to prevent complications resulting from pulmonary aspiration. However, trends in nutritional management are changing. NPO status and NG suction are not used as much, especially for mild cased.

The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate ventilation with nontraditional modes. The nurse understands that neuromuscular blocking agents provide: a. antianxiety effects. b. complete analgesia. c. high levels of sedation. d. no sedation or analgesia.

ANS: D Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties. Patients who receive NMBs must also receive sedatives and pain medication.

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg

ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum, indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.

In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that a. pain receptors in the abdomen are more likely to be localized. b. pain of a peptic ulcer is easily distinguished from that of heart attack. c. visceral pain often leads to tachycardia and hypertension. d. increasing intensity of pain is always significant.

ANS: D Pain assessment is challenging. Pain receptors in the abdomen are less likely to be localized and are mediated by common sensory structures projected to the skin. Therefore, distinguishing the pain of a peptic ulcer or cholecystitis from that of a myocardial infarction is often difficult. Abdominal pain often is caused by engorged mucosa, pressure in the mucosa, distension, or spasm. Visceral pain is likely to cause pallor, perspiration, bradycardia, nausea and vomiting, weakness, and hypotension. Increasing intensity of pain, especially after surgery or other intervention, is always significant and usually signifies complicating factors, such as inflammation, gastric distension, hemorrhage into tissue or the peritoneal space, or peritonitis.

The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b.Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.

ANS: D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.

The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure a. improves survival in patients with varices. b. decreases the risk of encephalopathy. c. decreases the incidence of ascites. d. decreases rebleeding.

ANS: D Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites occurs after all these procedures, and careful assessments and interventions are required in the care of this patient population.

The nurse is caring for a patient receiving a benzodiazepine intermittently. The nurse understands that the best way to administer such drugs is to: A. administer around the clock, rather than as needed, to ensure constant sedation. b. administer the medications through the feeding tube to prevent complications. c. give the highest allowable dose for the greatest effect. d. titrate to a predefined endpoint using a standard sedation scale.

ANS: D The best approach for administering benzodiazepines (and all sedatives) is to administer and titrate to a desired endpoint using a standard sedation scale. Administering around the clock as well as giving the highest allowable dose without basing it on an assessment target may result in excessive sedation. For greatest effect, most benzodiazepines are given intravenously.

After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F

ANS: D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104°F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis, and droplet precautions are appropriate for a patient with bacterial meningitis.

The patient is admitted with acute pancreatitis. The nurse should a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.

ANS: D The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease, gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed, these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. C-reactive protein increases within 48 hours and is a marker of severity.

The patient is being admitted to the hospital. At home, the patient takes an over-the-counter supplement of vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The nurse explains that a. the body does not store vitamins so the doctor will have to be called. b. the kidneys will produce enough vitamin D and that supplements are not needed. c. over-the-counter supplements are never given in the hospital. d. vitamin D is stored in the liver with a 10-month supply to prevent deficiency.

ANS: D The liver plays a central role in the storage, synthesis, and transport of various vitamins and minerals. It functions as a storage depot principally for vitamins A, D, and B12, where up to 3-, 10-, and 12-month supplies, respectively, of these nutrients are stored to prevent deficiency states. The kidneys do not produce vitamin D. Over-the-counter supplements are ordered, depending on the patient's status.

The nurse is concerned about the risk of alcohol withdrawal syndrome in a postoperative patient. Which statement by the nurse indicates understanding of management of this patient? a. "Alcohol withdrawal is common; we see it all of the time in the trauma unit." b. "There is no way to assess for alcohol withdrawal." c. "This patient will require less pain medication." d. "We have initiated the alcohol withdrawal protocol."

ANS: D The most important treatment of alcohol withdrawal syndrome is prevention. Many units have protocols that are initiated early to prevent the syndrome. Alcohol withdrawal syndrome is common; however, this statement does not indicate knowledge of management. The patient experiencing alcohol withdrawal may exhibit a variety of symptoms, such as disorientation, agitation, and tachycardia. Patients with substance abuse require increased dosages of pain medications.

The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing management, the nurse obtains an order for a. arm binders or splints. b. a higher dosage of lorazepam. c. propofol. d. soft wrist restraints.

ANS: D The priority in caring for agitated patients is safety. The least restrictive methods of keeping the patient safe are appropriate. If possible the tube or device causing irritation should be removed, but if that is not possible, the nurse must prevent the patient from pulling it out. Restraints are associated with an increased incidence of agitation and delirium. Therefore, restraints should not be used unless as a last resort for combative patients. The least amount of sedation is also recommended; therefore, neither increasing the dosage of lorazepam nor adding propofol is indicated and would be likely to prolong mechanical ventilation.

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the provider immediately.

ANS: D These are classic symptoms of epidural hematomas: injury, lucid period, and progressive deterioration. The provider must be notified of this neurological emergency so that appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient, and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the provider is a priority given the severity in change of neurological status.

The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the: a. Confusion Assessment Method (CAM-ICU). b. FACES assessment tool. c. Glasgow Coma Scale. d. Richmond Agitation Sedation Scale.

ANS: D Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing response to treatment. The Richmond Agitation Sedation Scale is a commonly used tool that has been validated. The CAM-ICU assesses for delirium. The FACES scale assesses pain. The Glasgow Coma Scale assesses neurological status.

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? - Hyperoxygenate during endotracheal suctioning. - Elevate the patient's head of the bed 30 degrees. - Apply bilateral heel protectors after repositioning. - Provide rest periods between nursing interventions.

ANS: D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient's plan of care; however, spacing out interventions is the priority