EXAM 2 Review

A1C

- Normal <5.9%, - Prediabetes > or = 6.5% - Managed 7%

Potassium

3.5-5 mEq/L

Fasting Blood Glucose

74-106

Chloride

98-106 mEq/L

Stimulation of what nerve will elicit the gag reflex?

Glossopharyngeal

The patient with newly diagnosed diabetes is displaying shakiness, confusion, irritability, and slurred speech. What should the nurse suspect is happening?

Hypoglycemia

Which ecg change is the most important for the nurse to report to the healthcare provider when caring for a patient with chest pain?

ST segment elevation

A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEg/L, and pH is 7.10. Which of the following interventions would you expect?

b. Insulin infusion at 5 units/h d. NS 1.5 L IV fluid bolus e. Potassium 29 mEq/L of IV fluid (pH less than < 7 include Sodium Bicarbonate)

What are some signs and symptoms of hypoglycemia? (SATA)

c. Faintness and weakness d. Nervousness, tremors e. Cold clammy skin

Which of the following laboratory values would be more common in patients with DKA?

pH 7.24

The patient with diabetes has a blood glucose level of 248 mg/dL. Which manifestation in the patient would the nurse understand as being related to this blood glucose level?

- Weakness and fatigue - blurred vision - Abdominal cramps

The nurse cares for a client with the syndrome of inappropriate antidiuretic hormone (SIADH), which assessment findings are likely to be identified in this client? (SATA)

- the client has full bounding pulse - The client has a decreased serum sodium

Magnesium

1.3-2.1 mEq/L

Pre-Diabetic

100-125

Sodium

136-145 mEq/L

Urine Osmo

280-320

Ideally fibrinolytic therapy (tPA) should be administered within how many hours of the onset of stroke symptoms?

3 - Onset: tPA (3 to 4 hours)

After the emergency department nurse has received a status report of the following patients with head injuries, which patient should the nurse assess first?

A 40-year-old patient whose right pupil is 10 mm and unresponsive to light

A patient is admitted with diabetes ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis?

Administer insulin and fluids intravenously

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Assessment of respiratory rate and effort

A patient with a spinal cord injury suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury. After checking the patient's vital signs and finding a systolic blood pressure of 310 and a heart rate of 48 bpm, the nurse suspects that the patient is experiencing which of the following?

Autonomic Dysreflexia → (Sudden onset of high BP)

Admission vital signs for a brain injured patient are blood pressure of 128.68 mm hg, pulse of 115 beats/min, and of respirations 26 breaths./min. Which set of vital signs, if taken 1 hour later will be of most concern to the nurse?

Blood pressure of 154/68 mm hg, pulse of 56 beats/min, respirations of 12 breaths/min - Cushing Triad: increased bp with widening pulse pressure, bradycardia, and altered respirations pg. 1303 - Chp. 56; Normal: 40 difference (Systolic - Diastolic)

Trauma to which vertebrae will cause ventilation dysfunction?

C3 to C5

Which statement best reflects the overall physiologic effects of Antidiuretic Hormone (ADH)?

Causes the kidneys to reabsorb water

The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours, the nurse suspects that the patient may be developing?

DI

Which pathophysiologic mechanism occurs in the patient with type 2 diabetes?

Decreased insulin secretion and insulin resistance

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Defibrillation

A nurse is caring for a patient who has a spinal cord injury. To prevent autonomic dysreflexia in this patient, the nurse should take measures for the patient to avoid?

Developing urinary retentions

The nurse will explain to the patient who has T2 spinal cord transection injury that?

Function of both arms should be retained

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and CPP of 85 mm Hg. What is the best interpretation by the nurse?

ICP is high, CPP is normal → Normal Range for ICP: 5 to 15; Normal Range for CPP: 60 to 100

Which of the following is an accurate restatement of the monro-kellie hypothesis?

If the volume of any 1 of the 3 components increases within the cranial vault then the volume from another compartment is displaced, so the total intracranial volume will not change

In a patient with central diabetes insipidus, what is the expected outcome of administering ADH during a water deprivation test?

Increase in urine osmolality

A patient has been admitted after the placement of a ventriculoperitoneal shunt. The nurse should monitor the patient for evidence of which condition?

Increased Intracranial Pressure

An unresponsive patient who has type 2 diabetes is brought to the ER and department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). What should the nurse anticipate doing

Inserting an IV catheter

The nurse is caring for a patient with type 1 diabetes who was admitted with the diagnosis of diabetic ketoacidosis (DKA). The patient is currently on an insulin drip. Serum laboratory values validate a potassium of 2.8 mEq/L. Which statement best describes the rationale for the patient's potassium levels with insulin therapy?

Insulin drives the potassium back into the cells

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

Intracranial pressure

A patient has been admitted with intracerebral hemorrhage. A CT of the patient's head reveals a large left parietal area bleed. Patient assessment includes T: 100.7 F, P: 98 beats/min and thready. R: 8 breaths/min, and BP: 188/100 mm Hg. Initial management of the patient includes which interventions?

Intubating and ventilating the patient

a patient is admitted with DKA. The nurse requests the practitioner to order a glycosylated hemoglobin (HA1C). What information does this test provide to the health care team?

It is an indicator of the patient's average blood glucose level over the previous 3 months

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about?

Lifestyle changes to lower blood glucose

The nurse receives a patient from ER following closed head injury. After insertion of a ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/50 mm Hg, heart rate 52 beats/min, Resp. Rate 24 breaths/min, SaO2 97% on supplemental oxygen at 45% via venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 20 mm Hg. Which provider prescription should the nurse institute first?

Mannitol 1 g intravenous → Normal Range ICP: 5-15

A patient has been admitted with a stroke. The nurse anticipates a practitioner order for which study before initiating therapy?

Noncontrast computed tomography → (No dye)

The nurse is providing insulin education for an elderly patient with long standing diabetes. A prescription has been written for the patient to take 20 units of insulin glargine at 10pm nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is?

Peakless (there's no peak, long acting) - Lispro- fast acting 30 min-3 hrs,

A patient has a tumor in the cerebellum. The nurse will plan interventions to:

Prevent falls

Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone?

Serum sodium 110 meq/l

The nurse has admitted a patient with a hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient?

Severe hyperglycemia with minimal or absent ketosis

Decreased urine osmolality is a sign of which disorder?

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

How is cranial nerve (CN) III originating in the midbrain assisted by the nurse for an early indication of pressure on the brain stem?

Test pupillary reaction to light

The nurse performs a neurological assessment on a client admitted with a traumatic brain injury. Which new finding does the nurse immediately report to the healthcare provider?

The client demonstrates decerebrate posturing

A patient who has type 2 diabetes is being prescribed for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test?

The patient took prescribed metformin today → it slows down the kidney function it contraindicated with procedure

The nurse cares for a patient with a spinal cord injury in the lower thoracic region. The nurse anticipates the patient will display which physical characteristics?

The patient will have full control of the arms, head, and neck

The nurse is caring for a patient with a head injury who has developed diabetes insipidus (DI). What medication would the nurse expect to be prescribed for the patient?

Vasopressin

A patient who is diagnosed with a subarachnoid hemorrhage is at risk for what to occur in the brain?

Vasospasms

The Code Blue nurse is responding to a patient in cardiac arrest. The nurse evaluates the rhythm and prepares to defibrillate the patient. Which one of the following rhythms did the nurse observe on the monitor?

Ventricular fibrillation

You're educating a patient about ischemic attacks (TIAs). Select all the options that are correct about this condition (SATA)

a. A TIAs is a warning sign that an impending stroke may occur e. TIAs are caused by a temporary decrease in blood flow to the brain

A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected?

a. Frontal lobe (Cognitive functions and control of voluntary movement or activity) b. Temporal lobe (Hearing) c. Occipital lobe (Vision) d. Parietal lobe (Processes information about temperature, taste, touch and movement) b. Temporal lobe (hearing)

A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse reviews the medication administration record to make sure the patient does not have which medication for the next 24 hours?

b. Warfarin c. Any antiplatelet drugs e. Aspirin

A 56 year old who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic (SIADH). The nurse would expect the initial laboratory results to include a(n)?

d. Decreased serum sodium

A nurse assesses a patient for a potential cerebrovascular accident (CVA). For which signs does the nurse assess? (SATA)

f. Sudden severe headache h. Inability to move an extremity i. Facial droop j. Difficulty understanding speech