HA exam 3

A client in the ICU is in MODS. Which organ systems will most likely show the effects of this client's deteriorating condition first? A Hepatic B Cardiovascular C Endocrine D Gastrointestinal E Neurologic F Respiratory

B Cardiovascular F Respiratory Eventually this organ system will be effected by MODS, but not as immediately as the respiratory and cardiovascular sytems. The lungs are usually the first to show signs of dysfunction. The cardiovascular system, because of the close association with the pulmonary system, is probably the second organ system showing signs of MODS.

The nurse is planning the care for a client with a systemic infection. Which of the following should be included in this client's plan of care? A Keep NPO B Oral care one time per shift and prn C Assess blood pressure daily D Intermittent urinary catheterization one time every shift

B Oral care one time per shift and prn Prevention of sepsis includes enforcement of infection control measures and measures to prevent nosocomial infections.

The nurse manager is concerned that a higher number of clients are developing MODS in the ICU. A staff inservice has been scheduled to discuss ways to contain this trend. Which of the following would be beneficial to include in this training? A The process of apoptosis must be identified early so that medication therapy can be started. B The white blood cell response to an assault helps contain the inflammatory process. C Efforts must be taken to help the clients prevent generalized responses to inflammation. D Medications must be given early to stop the release of mediators. E This process cannot be helped. F Every type of localized infection will develop into a systemic assault and lead to MODS.

B The white blood cell response to an assault helps contain the inflammatory process. C Efforts must be taken to help the clients prevent generalized responses to inflammation. Containment of the localized inflammatory response limits further damage to the host and preserves the integrity of uninvolved endothelial cells. Endothelial cell activation is not an all-or-nothing response.

A client diagnosed with MODS is demonstrating an alteration in oxygenation even though he is receiving a high concentration of oxygen through his endotracheal tube. Which pathologic change might this client be experiencing? A Dysregulated apoptosis B Tissue hypoxia C Microvascular coagulopathy D Uncontrolled systemic inflammation

B Tissue hypoxia Regional tissue hypoxia may occur even when the client appears to have adequate oxygenation. Even though a client might appear clinically to have adequate oxygenation, regional tissue hypoxia may occur, particularly in the intestinal tract and brain.

A patient with a foot infection says, "I can hardly walk on my foot because it is stiff and swollen." What nursing response is indicated? Select all that apply. A. "Infections in the foot always swell because of gravity." B. "The swelling and pain help remind you not to overuse your foot." C. "That is a sign of infection that would not have occurred if the area was only inflamed." D. "Swelling indicates that your infection is getting worse." E. "Inflammation often causes pain and tissue swelling."

B. "The swelling and pain help remind you not to overuse your foot." E. "Inflammation often causes pain and tissue swelling." Loss of function due to local swelling and pain is a physiologic change to help protect the site of injury.Pain and swelling are normal parts of the inflammatory response.

A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F. What nursing intervention is priority? A. Cover the patient with a warming blanket. B. Communicate with the provider. C. Increase frequency of turning and repositioning the patient. D. Increase the amount of humidification given via the ventilator.

B. Communicate with the provider. Communicating a low temperature to the provider and discussing alteration in the plan of care is an essential intervention.

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury. Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome? A. Urine output less than 400 mL/day B. Decreased PaO2 with an increase in FiO2 C. Alteration in level of consciousness D. Hypotension that responds to fluids

B. Decreased PaO2 with an increase in FiO2 Decreased PaO2 with an increase in FiO2 is correct because the lungs are usually the first organs to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome. Alteration in level of consciousness is probably already present with the closed head injury, and it also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia and not necessarily progress to multiple organ dysfunction syndrome.

A hospitalized patient develops multiple organ dysfunction syndrome. Which assessment findings would be the best indication of oxygenation status? Select all that apply. A. Absence of central cyanosis B. Decreased bowel sounds C. Unlabored respirations D. Mental slowing E. Normal pulse amplitude

B. Decreased bowel sounds D. Mental slowing Regional tissue hypoxia, particularly in the intestinal tract, is a complication of MODS. Decreased bowel motility, evidenced by decrease in bowel sounds, is a result of that hypoxia. Regional tissue hypoxia occurs in MODS, particularly in the brain. Slowing of mental processes results from that hypoxia.Increasing cardiac contractility is compensatory for decreased tissue perfusion. This change will result in normal pulse amplitude in many cases, so the presence of normal pulses does not rule out regional tissue hypoxia.The patient with MODS may appear clinically to have adequate oxygenation, so respiratory effort may also appear to be normal

A patient admitted for a gunshot wound to the leg and multiple abdominal stab wounds is transferred to the intensive care unit after surgery. The nurse would evaluate which finding as expected but as requiring monitoring? A. Blood pressure 170/104 mm Hg B. Elevated blood glucose level C. Serum potassium of 5.4 mEq/L D. Increase in body temperature

B. Elevated blood glucose level The first 24 hours after a body injury, the body responds with an increase in mobilization of carbohydrates and lipids. Glucose production increases in efforts to support wound healing. The body also responds by decreasing the amount of insulin produced. Because of these bodily responses, the nurse will most likely observe an elevated blood glucose level that will impact the patient's nutritional needs at this time. This finding is physiologically normal but will require monitoring as the patient heals.

The nurse is assessing a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement? A. Temperature of 97.8°F B. Heart rate of 70 bmp C. Resistance to ventilator-assisted breaths. D. Pink skin tone

B. Heart rate of 70 bmp Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement.

A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate? A. Decreasing the amount of oxygen being given B. Immediate initiation of fluid resuscitation C. Repeat of the testing in 4 hours D. Bedside fingerstick level of blood glucose

B. Immediate initiation of fluid resuscitation A lactate level of 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation.

The nurse is caring for a patient with disseminated intravascular coagulation who is bleeding from the gastrointestinal tract with a platelet count of 45,000. The nurse would anticipate which intervention for this patient? A. Heparin B. Intravenous platelets C. Warfarin D. Aspirin

B. Intravenous platelets Thrombocytopenia may be treated with the administration of concentrated platelets if the patient is actively bleeding or has a platelet count of less than 50,000.

A patient has developed disseminated intravascular coagulation. Which assessment would the nurse evaluate as reflecting the microthrombosis results of this disorder? A. Oozing from older intravenous access sites B. Jaundice C. Petechiae D. Ecchymoses

B. Jaundice Clinical manifestations of disseminated intravascular coagulation related to microthrombosis include oliguria, anuria, hematuria, and jaundice.

The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions would help optimize tissue perfusion for this patient? Select all that apply. A. Assess pulse oximetry. B. Maintain patency of the endotracheal tube. C. Administer pain medications as scheduled. D. Keep the environment calm and quiet. E. Maintain a darkened environment

B. Maintain patency of the endotracheal tube. C. Administer pain medications as scheduled. D. Keep the environment calm and quiet. Maintaining the integrity of the endotracheal tube is part of managing the care of a patient being mechanically ventilated. Mechanical ventilation helps to provide oxygen for perfusion.Managing pain helps to decrease oxygen consumption so that more oxygen is available for tissue perfusion.A calm environment decreases oxygen consumption.

A client in the ICU is experiencing a generalized response to inflammation. The nurse knows that this client is beginning to develop: A Apoptosis. B A normal adaptive response. C MODS. D Mediators. E SIRS. F Necrosis

C MODS. E SIRS.

Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction? A. 100 mg/dL B. 120 mg/dL C. 156 mg/dL D. 184 mg/dL

C. 156 mg/dL The goal for glucose control in this patient is approximately 150 mg/dL.

A patient is in the intensive care unit with multiple organ dysfunction syndrome. Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system? A. Increased flatus B. Abdominal cramps C. Absent bowel sounds D. Complaint of epigastric burning

C. Absent bowel sounds Because there is no objective measure of gastrointestinal function in the patient, the one assessment finding that could indicate dysfunction in this system would be the absence of normal bowel sounds.

A client in the ICU has been diagnosed with SIRS. Which of the following mechanisms is most likely to occur in response to this diagnosis? A. MODS B. MARS C. CARS

C. CARS One theory is that the SIRS response is rapidly followed in most patients by a compensatory anti-inflammatory response syndrome or CARS.

A patient has developed MODS. The nurse would monitor for development of which classic coagulation system findings? A. Large pulmonary emboli B. Deep vein thrombosis C. Clots in microcirculation D. Clot occlusion of coronary arteries

C. Clots in microcirculation MODS causes abnormal clotting in the small blood vessels (microcirculation) that results in microthrombosis that obstructs blood flow.

A patient admitted with an infected wound is demonstrating signs of improvement. The nurse would attribute this improvement to which physiologic process? A. Cortisol released from the adrenal glands B. Hypothalamus activating white blood cells C. Endothelial cells releasing mediators to contain the infection D. Mediators that decrease permeability of vessel walls

C. Endothelial cells releasing mediators to contain the infection Mediators, bioactive substances that stimulate physiologic changes in cells, are released from endothelial cells. It is these mediators that control inflammation, activate coagulation, deposit fibrin, and inhibit fibrinolysis to contain the inflammatory activity to the site of the infection.

A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome. Which laboratory results would confirm the nurse's suspicion of hepatic involvement? A. Increased fibrinogen level B. Decreased blood urea nitrogen C. Increased serum bilirubin D. Increased serum albumin

C. Increased serum bilirubin Liver dysfunction typically manifests as high levels of serum bilirubin. An increased serum bilirubin level would confirm the suspicion of hepatic involvement. Abnormalities in the liver would be likely to result in decreased fibrinogen levels.Low serum albumin levels would indicate liver involvement.

A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis. The patient's wife says, "I thought he didn't have any infection." How should the nurse respond? A. He probably had an infection that we did not recognize. B. He developed SIRS after getting MODS. C. Infection isn't necessary to develop SIRS, only a severe inflammation. D. Your husband's body is working against itself.

C. Infection isn't necessary to develop SIRS, only a severe inflammation. Pancreatitis is a severe inflammatory illness. SIRS can develop without infection.

The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable? A. There will be an increase in the blood flow to the brain. B. There is a decrease in the blood-brain barrier. C. There must be a decrease in another of the intracranial compartments. D. There will be an increase in the production of cerebrospinal fluid.

C. There must be a decrease in another of the intracranial compartments. The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro-Kellie hypothesis states that as the content of one of the intrancranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments.

client in the ICU has a MAP of 90 mm Hg and an ICP reading of 85 mm Hg. The nurse interprets these figures to mean: The client needs to be placed in the supine position. CPP is dropping. The client's blood pressure is too low. Cerebral perfusion pressure will be 175 mm Hg.

CPP is dropping.

A client is demonstrating signs of deteriorating brain function. Which of the following signs is the nurse likely to find upon assessment of this client? Eyes open spontaneously without stimulation Eyes fixed in mid-position Eyes move as head turns Respiratory rate within normal limits Cluster breathing Response to commands

Cluster breathing Eyes fixed in mid-position Cluster breathing is seen in worsening brain functioning. Respiratory patterns will change and spontaneous eye movements may be lost.

The health care team is working to prevent the development of MODS in a critically injured patient. The nurse would evaluate that these efforts have failed when which findings develop? A. SIRS is confirmed. B. Transfusion is required. C. Laboratory findings over the last 24 hours indicated renal failure. D. Respiratory distress and gastrointestinal bleeding have persisted for 36 hours.

D. Respiratory distress and gastrointestinal bleeding have persisted for 36 hours. MODS is the failure of two or more organ systems that persists beyond 24 hours.

A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery? A. Right vertebral B. Left posterior communicating C. Left middle cerebral D. Right middle cerebral

D. Right middle cerebral The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the right side of the brain controls the left side of the body.

A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position? A. The brain will compress the cerebral veins less in this position. B. The ventricles of the brain will drain better in this position. C. This position allows for less pain for the patient. D. The cerebral spinal veins are valveless and drain by gravity.

D. The cerebral spinal veins are valveless and drain by gravity. The cerebral spinal veins drain best via gravity, an important characteristic to remember when caring for patients with the risk for increased intracranial pressure as would be present in intracranial surgeries.

A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock? A. Cold extremities B. Increase in serum lactate levels C. Decreased SCVO2 D. Widening of pulse pressure

D. Widening of pulse pressure Since the patient's diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock.

A client in the ICU is demonstrating an increase in intracranial pressure. Which of the following could contribute to this assessment finding? Drop in blood pressure Tight oxygen face mask Fluid volume deficit Hyperflexed neck HOB elevated to 30 degrees Endotracheal tube ties tied tightly around the neck

Endotracheal tube ties tied tightly around the neck Hyperflexed neck

The nurse is caring for a client with a brain tumor that is obstructing the flow of CSF. Nursing care will most likely be focused on: Implement measures to maintain an above average blood pressure. Prepare for intubation because respiratory depression is pending. Keep the client as comfortable as possible, as death is imminent. Expect this client to have surgery or radiation to reduce the size of the brain tumor. Hyperoxygenate prior to suctioning. Explain to the client that the doctor might want to have a shunt placed to help reduce the amount of fluid building up in the brain.

Expect this client to have surgery or radiation to reduce the size of the brain tumor. Explain to the client that the doctor might want to have a shunt placed to help reduce the amount of fluid building up in the brain.

The nurse is planning the care for a client with a closed head injury. Which of the following would be appropriate to include in this client's plan of care? Maintain client in the supine position. Encourage anaerobic metabolism. Maintain oxygen level below maximum. Maintain blood pressure above normal. Maintain HOB elevated to 30 degrees. Encourage increase in cerebral blood flow.

Maintain HOB elevated to 30 degrees. Craniospinal veins are valveless and drain by gravity. Lactate does not cross the blood-brain barrier, therefore causing cerebral acidosis.

A client admitted to the ICU for a drug overdose is demonstrating an increase in intracranial pressure. The nurse knows that this caused by: Obstruction in the Circle of Willis. Decreased cardiac output. Metabolic changes of the blood-brain barrier. Inadequate oxygenation.

Metabolic changes of the blood-brain barrier. Most drugs do not cross the blood-brain barrier. This barrier can be physically disrupted or functionally impaired such as a drug overdose.

A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: Lactic acidosis. Severe hypotension. Rapid shallow respirations. Elevated temperature. Mental status changes. Oliguria.

Rapid shallow respirations. Elevated temperature. Sepsis is manifested by two characteristics, such as temperature >38 degrees C, heart rate >90 bmp, respiratory rate >20 breaths/minute, WBC count >12,000 per liter.

An older adult patient tells the nurse that he is "tired" of having his medication doses changed so many times and wants to find a doctor who "knows what he's doing." How should the nurse respond to this patient? 1. "Have you thought about cutting pills or add pills together to get the correct dose?" 2. "If you seriously want to change providers know some of the other doctors in the building are taking new patients." 3. "Frequent dose changes are necessary until the correct dose for you is determined." 4. "I know what you mean. It is annoying, but it is necessary."

Rationale 3: The patient is complaining about the physician's plan to "start low and go slow" when prescribing medications. The nurse's best response would be to explain how the different doses react in the body and the physician's attempt to prevent side effects or other pharmacological effects from the medications.

Upon assessment of a client in the neuro ICU, the nurse finds that one pupil is greatly dilated while the other restricts to light. This finding could be an indication of: Tonsillar herniation. Uncal herniation. Central herniation. Cingulated herniation.

Uncal herniation. Uncal or lateral transtentorial herniation can be evidenced by the classic sign of a unilaterally dilated pupil.

A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention? 1. 12 mm Hg 2. 22 mm Hg 3. 25 mm Hg 4. 30 mm Hg

1. 12 mm Hg The normal intracranial pressure ranges from 0 to 15 mm Hg.

A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient? 1. 50 mm Hg 2. 90 mm Hg 3. 70/40 mm Hg 4. 40/70 mm Hg

1. 50 mm Hg The cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure. In this patient the cerebral perfusion pressure would be inadequate and intervention is needed.

The nurse is caring for a patient who sustained a lacerated spleen from a motorcycle accident. Which complication is this patient most prone to experience because of the trauma? 1. Acute renal failure 2. Sepsis 3. Deep vein thrombosis 4. ARDS

1. Acute renal failure : Abdominal trauma, specifically a lacerated spleen, makes the patient prone to developing the complication of acute renal failure, abdominal compartment syndrome, or disseminating intravascular coagulation.

The nurse has adequately managed a patient's airway, breathing, and circulation. What is the next nursing action? 1. Assess level of consciousness. 2. Administer prophylactic tetanus toxoid as prescribed. 3. Auscultate heart sounds. 4. Assess the chest for paradoxical movements.

1. Assess level of consciousness. : The nurse should assess the patient's neurological status or level of consciousness as the next step.

A patient being treated for hypovolemia because of traumatic injuries has a blood pressure of 110/60 mmHg. What should the nurse do to validate this clinical finding? 1. Assess neck veins and urine output. 2. Measure oxygen saturation with oximetry. 3. Check serum potassium and sodium levels. 4. Check for pupillary constriction.

1. Assess neck veins and urine output. : Peripheral vasoconstriction, a compensatory mechanism, may artificially elevate blood pressure readings even though central arterial pressures are low in the patient being treated for hypovolemia because of traumatic injuries. To prevent misdiagnosis by focusing on one symptom while ignoring others, the nurse should monitor the trauma patient's blood pressure and at the same time assess neck veins, level of consciousness, and urine output.

The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings? Select all that apply. 1. Blood pressure is consistently above 95 diastolic. 2. The patient has had two recent hospital admissions to treat dehydration. 3. The patient reports drinking a glass of wine with dinner every evening. 4. The patient uses smokeless tobacco. 5. Testing has previously indicated the patient has hypercholesterolemia.

1. Blood pressure is consistently above 95 diastolic. 2. The patient has had two recent hospital admissions to treat dehydration. 5. Testing has previously indicated the patient has hypercholesterolemia.

An older adult with osteoarthritis has been told that he cannot have his painful knee replaced because of his cardiac status. The patient is having progressive difficulty with normal self-care activities. The nurse should monitor this patient for which condition? 1. Depression 2. Noncompliance 3. Dementia 4. Delirium

1. Depression

A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient's cardiac status? 1. Increase in cardiac output 2. Increase in blood pressure 3. Decrease in cardiac output 4. Decrease in blood pressure 5. No change in blood pressure or cardiac output

1. Increase in cardiac output 4. Decrease in blood pressure Decreased afterload causes cardiac output to increase. This will occur initially in septic shock, but will change as sepsis continues.Decrease in afterload results in decrease in blood pressure.

A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue. The nurse would explain this acceleration as due to which pathophysiology? 1. Increased concentration of sodium, chloride, and calcium in the brain cells 2. Reduced ability of the macrophages to reach the site of injury 3. Reduced concentration of magnesium and phosphorus in the brain cells 4. Increased concentration of potassium in the brain cells

1. Increased concentration of sodium, chloride, and calcium in the brain cells Increased intracellular concentrations of sodium, chloride, and calcium are due to the lack of oxygen reaching the cerebral tissues. Without oxygen, these electrolytes accumulate leading to toxicity within the mitochondria. This leads to further cerebral tissue death.

The nurse is providing care to a farmworker who was pinned against a steel gate by a horse. Deformation of the patient's pelvis and femurs is obvious, but little blood is present on the patient's clothing. Initial blood pressure is 110/68 mm Hg. What nursing interventions are indicated? Select all that apply. 1. Initiate intravenous access with a 16 gauge catheter. 2. Start fluid resuscitation with normal saline. 3. Prepare to administer vasopressor medication. 4. Turn the patient to assess for injuries to the back. 5. Prepare to insert a chest tube.

1. Initiate intravenous access with a 16 gauge catheter. 2. Start fluid resuscitation with normal saline. This patient's mechanism of injury and assessment indicates potential for femur and pelvic fractures, which can result in massive blood loss. The "normal" blood pressure may be related to pain and adrenaline release. Venous access with large gauge catheters is essential.This patient may be bleeding internally. Fluid resuscitation is indicated.

A nurse is preparing to conduct a neurological assessment on a patient who is not suspected for having neurological impairment. Which tests should the nurse perform? Select all that apply. 1. Observation for level of consciousness 2. Checking pupillary response to light 3. Ability to count by serial 7s 4. Assessing the blood pressure 5. Visual acuity

1. Observation for level of consciousness 2. Checking pupillary response to light 3. Ability to count by serial 7s 4. Assessing the blood pressure Simple testing for level of consciousness includes observing the patient for response to auditory or tactile stimuli.Simple penlight testing for pupillary response to light is a part of the abbreviated neuro check.Ability to count by serial 7s is not part of the abbreviated neuro check. Vital sign assessment is part of the abbreviated neuro check.

When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management? 1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain 2. Keeping the blood pressure under control pharmacologically 3. Transferring the patient for rehabilitation as soon as medically stable 4. Reestablishing blood flow to the infarcted area surgically

1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover.

The nurse is providing community education regarding stroke. Which information should be included? Select all that apply. 1. Stroke is caused by interruption of blood flow to the brain. 2. Stroke is the third-leading cause of death in the United States. 3. Stroke usually occurs simultaneously with myocardial infarction. 4. Rapid recognition of stroke symptoms can help decrease poor outcomes. 5. Stroke causes neurological defects.

1. Stroke is caused by interruption of blood flow to the brain. 2. Stroke is the third-leading cause of death in the United States. 4. Rapid recognition of stroke symptoms can help decrease poor outcomes. 5. Stroke causes neurological defects.

A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia? Select all that apply. 1. The confusion cleared when the patient was rehydrated. 2. The patient does not recognize her daughter. 3. The patient's daughter reports that her mother has been becoming increasingly confused over the last 6 months. 4. The patient's mentation was clear yesterday. 5. The patient does not recognize that she is confused.

1. The confusion cleared when the patient was rehydrated. 4. The patient's mentation was clear yesterday. Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported.Delirium is situational, reversible, and acute. Since the patient's mentation was clear yesterday, it is more likely to reflect delirium rather than dementia.

Which consideration will the nurse apply to the assessment of a patient who sustained penetrating trauma? 1. The extent of injury is related to the amount of energy transferred to the body tissues. 2. The amount of trauma sustained is related to the patient's nutritional status before the injury. 3. If the patient was well hydrated at the time of injury, the extent will be diminished. 4. The primary determinant of injury is the arc traveled by the penetrating object.

1. The extent of injury is related to the amount of energy transferred to the body tissues.

A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure. The nurse compares measurements to which critical normal value? 1. 50 mm Hg 2. 70 mm Hg 3. 120 mm Hg 4. 30 mm Hg

2. 70 mm Hg In order to ensure adequate cerebral oxygenation, the cerebral perfusion pressure must be maintained at greater than 70 mm Hg.

A patient is brought into the emergency department after a car accident. Injuries include fractured left femur, tibia, and fibula with a mild contralateral head injury. The nurse would identify this injury pattern as consistent with which situation? 1. Unrestrained front seat passenger of a motor vehicle 2. Adult pedestrian hit by an automobile 3. Unrestrained driver of a motor vehicle 4. Child pedestrian hit by an automobile

2. Adult pedestrian hit by an automobile The injuries of a fractured femur, tibia, and fibula on the same side with a contralateral head injury is an expected injury pattern for an adult pedestrian hit by a motor vehicle.

A patient was admitted to the emergency room for treatment of severe infection. Which objective parameters would increase the nurse's concern that shock is developing? Select all that apply. A. Serum lactate level is 5.4 mmol/L. B. Base deficit is -12 mmol/L. C. SvO2 is 68%. D. pHi is 6.9. E. Arterial pH of 7.38.

2. Base deficit is -12 mmol/L. 3. SvO2 is 68%. 4. pHi is 6.9. Lactate is the metabolic byproduct of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least to some part, on anaerobic metabolism rather than the normal aerobic metabolism.Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues.Low mucosal pH indicates development of acidosis.

After being medicated for postoperative pain an older patient becomes agitated and combative. Since this behavior has not been previously demonstrated the nurse conducts additional assessment for which most likely condition? 1. Depression 2. Delirium 3. Drug toxicity 4. Dementia

2. Delirium

The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicated the greatest possibility that this patient is having a stroke? 1. Radicular pain, decreased deep tendon reflexes, loss of bladder control 2. Dysphagia, hemianopsia, hemiparesis 3. Dystonia, dysphagia, dysarthria 4. Paresthesia, priaprism, loss of reflexes

2. Dysphagia, hemianopsia, hemiparesis The most common cluster of symptoms seen in a stroke is dysphagia, hemianopsia, and hemiparesis.

A 24-year-old woman was critically injured when hit by a car while she was walking to work. Emergency department staff has been working for one hour to stabilize her. Which parameters would the nurse evaluate as indicating the patient is adequately fluid resuscitated? Select all that apply. 1. Her core temperature is 98.2°F. 2. Her mean arterial pressure has been in the 70s for the last 30 minutes. 3. She is no longer tachycardic. 4. Her last lactate level was 2.0 mMol/L. 5. Her last sublingual capnography reading was 74.

2. Her mean arterial pressure has been in the 70s for the last 30 minutes. 3. She is no longer tachycardic. 4. Her last lactate level was 2.0 mMol/L. Rationale 2: MAP above 70 is an end point for trauma resuscitation. Rationale 3: HR less than 100 bpm is an end point for trauma resuscitation. Rationale 4: Lactate levels less than 2.2 mMol/L is an end point for trauma resuscitation.

A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of "not feeling like myself." What should the nurse consider during this assessment? 1. Aging causes sudden loss of function in organ systems. 2. In older adults diseases often present with uncharacteristic symptoms. 3. Many older adults do not participate in activities to support wellness. 4. Since the majority of 85-year-old patients live in an institutional setting they are exposed to more communicable diseases.

2. In older adults diseases often present with uncharacteristic symptoms. Older adults often manifest diseases in uncharacteristic ways, so diagnosis can be difficult or may be missed.

The nurse is assessing a patient injured in a fall from a tree. During the assessment the patient suddenly loses consciousness. Which interventions should the nurse use to protect this patient's airway? Select all that apply. 1. Hyperextend the neck. 2. Suction the patient. 3. Stabilize the neck. 4. Remove the tape the paramedics used to tape the patient's head to the backboard. 5. Pull up on the patient's lower jaw.

2. Suction the patient. 3. Stabilize the neck. 5. Pull up on the patient's lower jaw.

A pregnant patient in her third trimester has been involved in a motor vehicle accident. Which intervention should the nurse implement to treat the patient's symptoms of hypotension? 1. Turn the patient to the right lateral position. 2. Turn the patient to the left lateral position. 3. Place the patient in Trendelenburg's position. 4. Place the patient in the supine position.

2. Turn the patient to the left lateral position. Placing the patient in the left lateral position shifts the uterus to the left, thus, preventing the heavy uterus from compressing the inferior vena cava against the spinal column and decreasing venous return and preload.

An older adult says, "I cannot believe that I have had a heart attack. I thought I had stomach flu and a backache." What nursing response is indicated? 1. "I am also surprised that you had a heart attack. Your symptoms did not sound that severe." 2. "Usually a patient has chest and arm pain with a heart attack." 3. "The symptoms of heart attack change as people age and may include back pain or stomach problems." 4. "It is rare but a backache and a stomach ache can occur as a signal of a heart attack."

3. "The symptoms of heart attack change as people age and may include back pain or stomach problems." Elderly patients with cardiac ischemia and an acute myocardial infarction or heart attack may have atypical symptoms. These symptoms include shortness of breath, abdominal, throat, or back pain, syncope, acute confusion, flulike symptoms, stroke, and/or falls. Because these symptoms are atypical, diagnosis and treatment might be delayed.

A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which post-traumatic complication should the nurse focus on when providing care to this patient? 1. Abdominal compartment syndrome 2. Sepsis 3. ARDS 4. Acute renal failure

3. ARDS The patient with a thoracic injury is prone to developing the post-traumatic complications of ARDS and DIC.

A patient brought into the emergency department with injuries sustained from a motor vehicle accident (MVA) is complaining of abdominal pain and begins to vomit. The nurse suspects injury from which most likely source? 1. Shearing 2. Deceleration 3. Compression 4. Acceleration

3. Compression Compression is the process of being pressed or squeezed together with a resulting reduction in volume or size. The small bowel may be compressed between the vertebral column and the lower part of the steering wheel or an improperly placed seat belt. The bowel may rupture. Because the patient complained of abdominal pain and started to vomit, the nurse should suspect that the patient sustained a compression force injury.

A patient is admitted to the intensive care unit accompanied by a family member who says, "He suddenly started acting funny and couldn't remember where he was." The nurse would anticipate that first assessment efforts would focus on which condition? 1. Hypovolemic shock 2. Cerebral infection 3. Ischemic stroke 4. Drug overdose

3. Ischemic stroke Even though there are many causes of impaired mentation in patients who have not sustained a head injury, ischemic stroke has been found to be the most frequent cause of impaired mentation on admission to the intensive care unit. The patient should be assessed first for an ischemic stroke.

The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment the nurse notes that the patient's afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis? 1. Decreased circulating volume 2. Reaction to antibiotics used to treat sepsis 3. Marked vasodilation 4. Decreased ventricular contractility

3. Marked vasodilation Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance. Ventricular contractility may be reduced following the release of myocardial depressant factor as a result of sepsis. However, this is not the primary cause of decreased vascular resistance.

A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated? Select all that apply. 1. Insert a nasogastric tube for nutritional support. 2. Monitor for renal stone formation. 3. Monitor for deterioration of neurological status. 4. Reposition every 15 minutes.

3. Monitor for deterioration of neurological status. Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation.

The nurse is preparing to assess a motor vehicle accident victim who was lap and shoulder harness restrained. Due to the mechanism of injury the nurse will look for which most common injuries? Select all that apply. 1. Lumbar spine fractures 2. Fractured patella 3. Pulmonary contusion 4. Flexion fracture of the cervical spine 5. Contusion of the small bowel

3. Pulmonary contusion 5. Contusion of the small bowel Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Pulmonary contusions are an example of this injury.Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Small bowel contusions are an example of this injury.

A teenage patient comes into the emergency department with an arrow lodged in his right lower thoracic region. Which nursing intervention is indicated? 1. Have the patient assume a left side lying position and pull on the arrow to remove it. 2. Slowly move the arrow to the left and right to attempt to dislodge it. 3. Stabilize the arrow by padding around the wound with gauze rolls. 4. Slowly rotate the arrow to attempt to dislodge it.

3. Stabilize the arrow by padding around the wound with gauze rolls. If the offending weapon is impaled in the body, it is critical that the object be left in place and protected from further movement until definitive surgical intervention is available. Protective padding can be placed around the object, such as gauze rolls or abdominal pads. The nurse should stabilize the arrow by padding around the wound with gauze rolls.

The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient's pupils to be pinpoint and nonreactive to light. The nurse takes into consideration that this finding can be due to which situations? : Select all that apply. 1. The patient was given atropine sulfate for bradycardia. 2. The patient has increased blood glucose. 3. The patient may have taken an opioid drug overdose. 4. The patient has sustained compression of the oculomotor nerve. 5. The patient has sustained damage to the pons.

3. The patient may have taken an opioid drug overdose. 5. The patient has sustained damage to the pons. Opiod drug overdose will result in pinpoint, nonreactive pupils.Damages to the pons will result in fixed and pinpoint pupils.

Diagnostic testing reveals that a patient has areas of cerebral focal infarctions. The nurse plans care with the realization that which outcome is likely? 1. The patient will likely deteriorate into multiple system organ failure. 2. These areas of ischemia will likely extend into the brainstem. 3. The patient's symptoms will likely resolve with treatment. 4. The patient's symptoms will progress rapidly.

3. The patient's symptoms will likely resolve with treatment. : In focal ischemia there is some degree of collateral circulation that remains. This allows for the survival of neurons and for reversal of neuronal damage after periods of ischemia. Focal ischemia is treatable because of the potential for recovery therefore the patient's symptoms will most likely resolve with treatment.

The daughter of an older adult calls the emergency department (ED) triage nurse and reports that her mother hit her head "very hard" while getting into the car about 10 minutes ago. There is no bleeding. The daughter asks what she should watch for in her mother. How should the nurse respond? 1. "As long as she does not develop a severe headache she is probably okay. Be sure to bring her to the ED if that happens." 2. "As long as your mother does not begin vomiting she is probably not severely injured. If she does begin to vomit, bring her in immediately." 3. "Watch her for the next hour or two. If she seems okay after that she is not likely to have a severe injury. Bring her in to the ED if you are concerned." 4. "In older adults the changes are very subtle and can develop over several hours or even days. Bring her to the ED if you have any concerns."

4. "In older adults the changes are very subtle and can develop over several hours or even days. Bring her to the ED if you have any concerns."

The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication? Select all that apply. 1. A patient who sustained a severe chest contusion. 2. A patient hospitalized for treatment of drug overdose. 3. A patient who sustained severe head trauma. 4. A patient hospitalized for treatment of pneumonia. 5. A patient diagnosed with sepsis.

4. A patient hospitalized for treatment of pneumonia. 5. A patient diagnosed with sepsis.

The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery. Which nursing diagnosis is the priority for care in the acute phase of this disease process? 1. Altered Nutrition: Less than Body Requirements 2. Total Self-Care Deficit 3. Decreased Intracranial Aadaptive Capacity 4. Altered Cerebral Tissue Perfusion

4. Altered Cerebral Tissue Perfusion The priority for care in the early and acute phase of a thrombotic stroke is to maintain the effect perfusion to the area near the infarct, the penumbra.

When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor? 1. Hypertension 2. Use of anticoagulants 3. History of atherosclerosis of cerebral arteries 4. Atrial fibrillation

4. Atrial fibrillation

An older adult has been prescribed medication to control hypertension. Today she says, "I took this same medication years ago, but I'm having more side effects this time." What should the nurse consider before replying? 1. Many antihypertensive medications have similar names so the patient could have confused the drugs. 2. Older women often decrease oral fluid intake, which would change response to the drug. 3. The older pancreas cannot supply enzymes to metabolize the drugs as early in the digestive system. 4. Changes in the blood-brain barrier may make older patients more sensitive to some side effects.

4. Changes in the blood-brain barrier may make older patients more sensitive to some side effects. The side effects of antihypertensive drugs are generally problems with dizziness or weakness. The blood-brain barrier changes allow the drug to have more of these effects in older patients.

While conducting the secondary survey of a patient admitted with multiple traumas, the nurse assesses paralysis of the patient's left lower leg. Which nursing intervention is indicated? 1. Move the patient to a semi-sitting position. 2. Support limb by placing it on a pillows. 3. Turn the patient to assess the back. 4. Immediately immobilize the patient.

4. Immediately immobilize the patient. If during the complete neurological examination the nurse assesses any evidence of paralysis or paresis, prompt immediate immobilization of the entire patient should occur if not already done. The nurse should remember that during the secondary survey, the patient may manifest findings requiring return to interventions recognized as part of the primary survey.

A patient is recovering from surgery to clip an aneurysm. The nurse would anticipate managing which interventions to help prevent cerebral vasospasm? 1. Infusion of packed red blood cells 2. Diuretic therapy 3. Oral fluid restriction 4. Intravenous fluid augmentation

4. Intravenous fluid augmentation Postoperative complications associated with the clipping of an aneurysm include cerebral vasospasm. Vasospasm decreases perfusion to brain tissue and is prevented and treated with "triple H therapy": hypervolemia, hypertension, and hemodilution. This combination of therapies is used to augment cerebral perfusion pressure by raising systolic blood pressure, cardiac output, and intravascular volume to increase cerebral blood flow and minimize cerebral ischemia.

From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated? 1. Use the prn order for morphine to control the patient's pain. 2. Use wrist restraints to maintain monitoring devices and lines. 3. Restrict visitors to times when the patient's mentation is clearest. 4. Reorient the patient to the environment as needed.

4. Reorient the patient to the environment as needed. One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner.

A patient, admitted with syncope, is diagnosed with an 80% stenosis of the left carotid artery. In addition to assessing the patient's speech, the nurse should focus the assessment on the presence or development of which other findings? 1. Vertigo and cranial nerve palsies 2. Monocular blindness and left-sided sensory loss 3. Double vision and ataxia 4. Right sided hemineglect, sensory and motor loss

4. Right sided hemineglect, sensory and motor loss The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke.

A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family? 1. CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain. 2. The CT scan will evaluate how much brain swelling is associated with this stroke. 3. The CT scan will pinpoint the exact area of the brain affected by the stroke. 4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke.

4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke. A CT scan will be used to rule out a hemorrhagic stroke from an ischemic stroke especially if thrombolytic therapy is being considered and to determine any areas of localized hematoma formation as a result of a hemorrhage.

The charge nurse in the ICU is making client assignments with the nurses. Of the 10 clients in the unit, 2 are considered critical due to their potential to develop either primary or secondary MODS. Which of the following clients would be at risk for this development? A A 48-year-old male hemophiliac admitted to the unit for observation after complaining of chest pain. B A 24-year-old female client post craniotomy for a repair of A-V malformation. C A 35-year-old male client recovering from a motor vehicle accident D A 54-year-old female in diabetes ketoacidosis. E A 58-year-old male client, post myocardial infarction, with a 25-year history of type 2 diabetes. F A 68-year-old male client currently being treated for an infection in a replaced hip.

A 58-year-old male client, post myocardial infarction, with a 25-year history of type 2 diabetes. A 68-year-old male client currently being treated for an infection in a replaced hip. Risk factors for primary MODS include severity of injury, shock, or SIRS. Risk factors for secondary MODS include infection, transfusions, and multiple surgical procedures.

The nurse is making a follow-up call to a patient recently released from the acute care unit following treatment for thrombocytopenia. Which patient statements would the nurse consider reason to suggest contacting the primary health provider? Select all that apply. A. "You didn't tell me that I would have such bad, smelly diarrhea once I got home." B. "I feel fine but my skin is a little off color." C. "My appetite is coming back slowly." D. "I was able to take a walk with my dog yesterday." E. "I keep getting headaches in the late afternoon if I am tired."

A. "You didn't tell me that I would have such bad, smelly diarrhea once I got home." B. "I feel fine but my skin is a little off color." E. "I keep getting headaches in the late afternoon if I am tired." Diarrhea, particularly diarrhea with a very bad smell, may indicate gastrointestinal bleeding. This finding requires further assessment.Skin condition can reveal information about health. This comment may indicate the patient has jaundice, petechiae, or other findings associated with bleeding. This finding requires further assessment.Headaches should be investigated further as they may indicate bleeding disorders.

A patient arrives at the emergency department following a gunshot wound to the abdomen. He is unresponsive and has cool, clammy skin. Paramedics were unable to initiate a peripheral IV and the patient's abdominal wound is bleeding briskly. The nurse bases emergency interventions on which priority nursing diagnoses? Select all that apply. A. Decreased Cardiac Output B. Fluid Volume Deficit C. Risk for Shock D. Ineffective Breathing Pattern E. Altered Tissue Perfusion: Cerebral

A. Decreased Cardiac Output B. Fluid Volume Deficit C. Risk for Shock E. Altered Tissue Perfusion: Cerebral Blood loss has decreased this patient's cardiac output as evidenced by cool and clammy skin.Due to the loss of blood through a "briskly" bleeding abdominal wound, the patient has fluid volume deficit. Decreased consciousness and cool, clammy skin are evidence of this diagnosis. The patient is at risk for hypovolemic shock due to the nature of this wound. There is no evidence presented that supports this nursing diagnosis. The patient may still be breathing at an acceptable rate and depth. Lack of responsiveness may indicate poor perfusion to the brain. Since the patient is losing blood rapidly the nurse would act to support cerebral perfusion.

Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction in a critically ill patient who is being mechanically ventilated? SATA A. Enforcing hand washing before and after touching a patient B. Following an evidence-based ventilator bundle C. Using urinary catheters to prevent perineal skin breakdown D. Complying with turning and repositioning schedules E. Restricting visitors to immediate family only

A. Enforcing hand washing before and after touching a patient B. Following an evidence-based ventilator bundle D. Complying with turning and repositioning schedules

The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with MODS. Which information must the nurse obtain before this measurement can be calculated? SATA A. Heart rate B. Central venous pressure C. Mean arterial pressure D. Temperature E. PaFiO2

A. Heart rate B. Central venous pressure C. Mean arterial pressure

A patient who underwent transurethral resection of the prostate 5 days ago returns to the emergency department. After assessing the patient and obtaining laboratory results the nurse notes a temperature of 96.8°F, a respiratory rate of 26, and a white blood cell (WBC) count of 3,000 mm3. The nurse anticipates additional treatment for which disorder? A. Systemic inflammatory response syndrome B. Homeostasis C. Localized inflammation D. Multiple organ dysfunction syndrome

A. Systemic inflammatory response syndrome Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4,000/mm3. These findings meet the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria of sepsis.

A critically ill patient is diagnosed with disseminated intravascular coagulation. Which history would the nurse evaluate as indicating increased risk for this development? A. The patient had a transfusion reaction yesterday. B. The patient was intubated and placed on mechanical ventilation 2 days ago. C. The patient has a long history of hypertension. D. The patient passed a kidney stone this morning.

A. The patient had a transfusion reaction yesterday.

A patient diagnosed with sepsis and multiple organ dysfunction syndrome has developed acute renal failure. Which arterial blood gas (ABG) result would the nurse expect to find? A. pH = 7.30, PaCO2= 38, HCO3 = 16, PaO2 = 60 B. pH = 7.50, PaCO2 = 30, HCO3 = 26, PaO2 = 90 C. pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70 D. pH = 7.46, PaCO2 = 42, HCO3= 28, PaO2 = 80

A. pH = 7.30, PaCO2= 38, HCO3 = 16, PaO2 = 60 The choice pH = 7.30, PaCO2 = 38, HCO3 = 16, and PaO2 = 60 metabolic acidosis is correct because of anaerobic metabolism due to hypoxia and an increase in lactic acid and the kidney's inability to excrete hydrogen ions. In acute renal failure metabolic acidosis can be caused by loss of bicarbonate.