Exam 4

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)?

B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair

What are the five classic signs of placental abruption?

Bleeding, uterine tenderness, uterine irritability, abdominal or low back pain, high uterine resting tone.

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury?

Bradycardia

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

Bradycardia and hypertension

Treatment of DIC

Cryoprecipitate Plasma Platelets

Terbutaline

Halt preterm labor

drugs used to manage postpartum hemorrhage

Oxytocin Methylergonovine Carboprost

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?

The client with enlarged lymph nodes in the neck.

A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?

The patient should avoid close contact with his daughter for 2 months.

Risk factors leading to DIC

infection or malignancy

A client with Hodgkin lymphoma is receiving information from the oncology nurse. The client asks the nurse why it is necessary to stop drinking and smoking and stay out of the sun. Which response by the nurse would be best?

"It's important to reduce other factors that increase the risk of second cancers."

Early postpartum hemorrhage is defined as a blood loss greater than:

500 mL in the first 24 hours after vaginal delivery.

A nurse is teaching a 53-year-old man about prostate cancer. What information should the nurse provide to best facilitate the early identification of prostate cancer?

A Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.

An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC?

A client who is being treated for septic shock

A man tells the nurse that his father died of prostate cancer and he is concerned about his own risk of developing the disease, having heard that prostate cancer has a genetic link. What aspect of the pathophysiology of prostate cancer would underlie the nurse's response?

A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer.

A nurse is caring for a client with Hodgkin lymphoma at the oncology clinic. The nurse should identify what main goal of care?

A. Cure of the disease

A nurse is providing an educational event to a local men's group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group?

African american

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

Autonomic dysreflexia

The clinical nurse educator is presenting health promotion education to a client who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions?

Avoiding highly crowded public places

A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?

Change in bowel habits

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Cough or change in chronic cough

Complications of abruptio placenta

DIC

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate

The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain?

Displacing or shifting cerebral spinal fluid (CSF) Increasing the absorption of CSF Decreasing cerebral blood volume

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

Ecchymosis over the mastoid

A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was "knocked out," but came to and "seemed okay." Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?Bradycardia and hypertension

Emergency craniotomy

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company?

Fit all employees with protective masks.

A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patient's care in the knowledge of potential complications. What assessment should the nurse prioritize?

Frequent abdominal auscultation

Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to the possibility of autonomic dysreflexia?

Headache and rising blood pressure

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite?

High levels of alcohol consumption

A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursingdiagnosis should the nurse associate with this complication of AIDS?

Impaired Skin Integrity Related to Kaposis Sarcoma

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?

Ineffective airway clearance due to high cervical spinal cord injury

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client?

Maintain head of bed (HOB) elevated at 30 to 45 degrees

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Maintaining patent airway

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication?

Mannitol

A 20-year-old client with no medical history arrives at a walk-in/urgent care clinic reporting swelling on the left side of the neck. On palpation, the lymph nodes on the neck are painless, firm but not hard. What is the next appropriate intervention for this client?

Perform diagnostic studies to rule out any infectious origin at a hospital

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the patient's BP.

An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurse's most appropriate response to the patient's complaint?

Promptly refer the patient for medical assessment.

A client is awaiting test results to diagnose Hodgkin lymphoma. The nurse knows that which result is the hallmark for the diagnosis of this condition?

Reed-Sternberg cells

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of her perineum. What is the nurse's best action?

Report the finding promptly to the primary care provider.

The patient was in a traffic collision and is experiencing loss of function below C4. Which effectmust the nurse be aware of to provide priority care for the patient?

Respiratory diaphragmatic breathing

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Severe TBI.

The patient is diagnosed with Brown-Séquard syndrome after a knife wound to the spine. Which description accurately describes this syndrome?

Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the level of the lesion

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action?

Take the patient's blood pressure.

A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock?

Tetraplegia with total sensory loss

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider?

The patient will require full assistance for all aspects of elimination.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Vigorously massage the fundus.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure

Inspecting the placenta

be sure that it all came out there are no tears in the placenta

typical signs of hemorrhage

falling blood pressure, increasing pulse rate, and decreasing urinary output

s/s of sub involution

fundal height higher than expected boggy uterus fails to turn serosa to alba

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?

hematoma

The nurse knows that a measure for preventing late postpartum hemorrhage is to:

inspect the placenta after delivery.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony

causes of post partum hemorrhage

uterine atony lacerations retained fragments

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

vomits

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?

Ensure that the player is not moved.

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?

Epidural

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Few early symptoms

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination?

Ipsilateral motor loss and contralateral sensory loss below C7

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding?

It indicates an injury at the midbrain level.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing).

A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding?

Large uterus with painless dark red blood mixed with clots

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increased intracranial pressure

A client has received the news that the client's treatment for Hodgkin lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the client receives regular health assessments in the future due to the risk of which complication?

Secondary malignancy

A patient's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patient's health problem?

The patient's polyps constitute a risk factor for cancer.

Which intervention should you perform in the acute care of a patient with autonomic dysreflexia?

Urinary catheterizatio

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?

Vigilant monitoring of fluid balance

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma

Sub-classification of distributive shock

neurogenic, septic and anaphylactic

Nurse care plan for MODS

prepare family for the worst

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)?

tachycardia

A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale?

to reduce intestinal bacteria levels