Med Surg Exam 3 Practice Questions

The nurse is assessing a client with increased ICP. The nurse should notify the HCP about which early change in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupils D. Decrease in level of consciousness (LOC)

D A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. CHanges in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abruptly ceasing all activity C. Facial grimaces, patting motions, and lip smacking D. Loss of consciousness, body stiffening, and violent muscle contractions

D A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consist of loss of consciousness, dilated pupil, and muscular stiffening or contraction, which lasts about 20-30 seconds. The clonic phase involves repetitive movements, The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (jerking in the extremity s[reading to other areas of the body). An absence seizure usually occus in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involved facial grimacing with patting and smacking

Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? A. Maintain the client on bed rest B. Administer a sedative as prescribed C. Close the door to the room to minimize stimulation D. Administer carbamazepine 200 mg PO, twice per daay

D Carbamazepine is an anticonvulsant that helps prevent further seizures and is the most effective intervention for preventing seizure risk while the client is undergoing diagnostic tests for seizures. Bed rest, sedation, and providing privacy dont minimize the risk of seizures

The nurse should teach the client with diverticulitis to integrate which measure into a daily routine at home? A. Using enemas to relieve constipation B. Decreasing fluid intake to increase the formed consistency of the stool C. Eating a high-fiber diet when symptomatic with diverticulitis D. Refraining from straining and lifting activities

D Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is present.

Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes 2000 mL of IV fluid intake, 500 mL of drainage from the NGT, and 700 mL of urine for a total output of 1,200 mL. How should the nurse interpret these findings? A. Decreased renal function B. The NGT not draining well C. Extension of the obstruction D. Inadequate fluid replacement

D Considering that there is usually 1 L of insensible fluid loss, this client's output exceeds his intake, indicating deficient fluid volume, The kidneys are concentrating urine in response to low circulating volume, as evidenced by a urine output of <30 mL/h. This indicates that increased fluid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain doesn't affect urine output. There are no data to suggest that the obstruction has worsened.

The nurse is assessing a client with a head injury for decerebrate posturing. Which position indicates the client has decerebrate posturing? A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers B. Back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet C. Supination of arms and dorsiflexion of the feet D. Back arched and rigid extension of all four extremities

D Decerebrate posturing occurs in clients with damage to the upper brain stem, midline, or pons and is demonstrated clinically by arching of the back, rigid extension if the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers described decorticate postuing, which indicates damage to corticospinal tracts and cerebral hemispheres.

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. What should the nurse do to test the client's ability to move? Ask the client to: A. Shrug shoulders against downward resistance B. Pull arm up from a resting position against resistance C. Straighten arm from a flexed position against resistance D. Grasp the nurse's hands with both hands and squeeze

D The correct motor function test for C8 is a hand-grasp check. The motor function check for C4 and C5 is shoulder shrugging against downward pressure of the examiner's hands. The motor function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor function check for C7 is an arm straightening out from a flexed position against resistance

A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. What should the nurse do to provide wound care? A. Remove the dressing and leave the incision open to air B. Remove the drain if wound drainage is minimal C. Gently irrigate the drain to remove exudate D. Clean the area around the drain moving away from the drain

D The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated

A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse initiate care for this client? A. Request a prescription for haloperidol B. Maintain a quiet environment C. Assure the client's safety D. Approach the client using short sentences

D, C, B, A The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short sentences when explaining the care given. The nurse should also assure the client's safety by protecting the client from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention is used only when other plans for care are not effective. When the underlying problems related to the head injury are resolved, the delirium likely will improve

The nurse has established a goal to maintian intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. A. Encourage the client to cough to expectorate secretions B. Elevate the HOB 15-20 degrees C. Contact the HCP if ICP is >28 D. Monitor neurologic status using the Glasgow Coma Scale E. Stimulate the client with active range of motion exercises

B, C, D The nurse should maintain ICP by elevating the HOB 15-20 degrees and monitoring neurologic status. An ICP of 28 with 20-25 as upper limits of normal indicates increased ICp, and the nurse should notify the HCP. Coughing and range of motion exercises will increase ICP and should be avoided in the early postoperative stage

The nurse is observing the UAP give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which? A. Positions the client on her back with a small pillow under the head B. Keeps portable suctioning equipment at the bedside C. Opens the client's mouth with a padded tongue blade D> Cleans the clients mouth and teeth with a toothbrush

A The UAP should position an unconscious client on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he or she aspirated. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush

The client has a sustained increased ICP of 20. Which client position would be most appropriate? A. The head of the bed elevated 15-20 degrees B. Trendelenburg's position C. Left Sims' position D. The head elevated on two pillows

A The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 15-20 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburgs position places the client's head lower than the body, which would increase ICP. Sims position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP

An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? A. Establish an airway B. Determine the identity of the client C. Stop bleeding from open wounds D. Check for a neck fracture

A The highest priority for a client with multiple head and neck injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Determining the client's identity, blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established

The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has which symptom following the seizure? A. Drowsiness B. Inability to move C. Paresthesia D. Hypotension

A The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure

A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply. A. Percuss the abdomen to note resonance and tympany. B. Percuss the liver to note lack of dullness. C. Monitor the vital signs for fever, tachypnea, and bradycardia. D. Assess presence of polyphagia and polydipsia. E. Auscultate bowel sounds to note frequency.

A, B, C, E Percussion will show resonance and tympany indicating paralytic ileus. Lack of liver dullness may indicate free air in the abdomen. The client with peritonitis will have fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness, and there will be absent bowel sounds. The client will not demonstrate excessive thirst but may have anorexia, nausea, and vomiting as peristalsis decreases.

The nurse is instructing a client about postoperative care following a laparoscopic appendectomy. What information should the nurse include in the teaching plan? Select all that apply. A. "Nausea, gas, and diarrhea are normal for several days" B. "You can return to work in 1-3 weeks" C. "Follow a low-residue diet until the incision has healed" D. "Take a tub bath to relieve abdominal swelling" E. "You can drive when you are not taking pain medications"

A, B, E The nurse should instruct the client that nausea, abdominal distention from gas, and diarrhea are mormal following an appendectomy. The client will be able to return to work and usual activities in 1-3 weeks. The client doesnt need to follow a low-residue diet but may prefer a bland diet id the client has nausea or an upset stomach. The client can drive if not taking pain medication. The client should not take a tub bath until the incision has healed.

A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The HCP has written the following prescriptions: For the client to be ad lib, have narcotics for pain, have a nasogastric tube inserted if needed, and for IC, Lactated Ringers, and hyperalimentation fluids. What should the nurse do in order of priority from first to last? A. Assist with ambulation to promote peristalsis B. Insert a nasogastric tube C. Administer IV Lactated Ringers D. Start an infusion fo hyperalimentation fluids

A, C, B, D The nurse should first help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. Next, the nurse should initiate IV fluid therapy to correct fluid and electrolyte imbalances (sodium and potassium) with lactated ringers to correct interstitial fluid deficit. Nasogastric decompression of the GI tract to reduce gastric secretions and nasointestinal tubes may also be used as necessary. Lastly, hyperalimentation can be used to correct protein deficiency from chronic obstruction, paralytic ileus, or infection.

When communicating with a client who has aphasia, which approaches are helpful? Select all that apply A. Present one thought at a time B. Avoid writing massages C. Speak with normal volume D. Make use of gestures E. Encourage pointing to the needed object

A, C, D, E The goal of communication with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. A. Systolic BP B. Urine output C. Breath sounds D. Cerebral perfusion pressure E. Level of pain

A, D The nurse must monitor the systolic and diastolic BP to obtain the MAP, which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP

A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which signs and symptoms? Select all that apply. A. Projectile vomiting B. Significant abdominal distention C. Copious diarrhea D. Rapid onset of dehydration E. Increased bowel sounds

A, D, E Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting.Intestinal obstructions in the large intestine usually evolve slowly and produce persistent pain, and vomiting is less common. Clients with a large intestine obstruction may develop obstipation and significant abdominal distention.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating? A. Have a preference for foods high in salt B. Eat food on only half of the plate C. Forget the names of foods D. Be unable to swallow liquids

B Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)? A. Place the client in a jacket restraint B. Wrap the hands in soft "mitten" restraints C. Tuck the arms and hands under the sheet D. Apply a wrist restraint to each arm

B It is best for the client to wear mitts, which help prevent the client from pulling on the IV with out causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the sheet restricts movement and adds to feelings of being confined, all of which would add to the agitation and increase ICP

What is priority nursing assessment in the first 24 hours after admission of the client with a thrombolytic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased ICP. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The nect morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply. A. Find a television so that the client can view the football game B. Determine if the client's pupils are equal and react to light C. Ask the client if he has a headache D. Arrange for the client to be with his Wife and baby E. Administer a sedative

B, C The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinica manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP

What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person, and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably

C A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effetive rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

The client will have an EEG in the morning. The nurse should instruct the client to have which foods/fluids for breakfast? A. No foods or fluids B. Only coffee or tea if needed C. A full breakfast as desired without coffee, tea, or energy drinks D. A liquid breakfast of fruit juice, oatmeal, or smoothie

C Beverages containing caffeine, such as coffee, tea, cola, and energy drinks, are withheld before EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client ca have the entire meal except for the coffee. The client doesnt need to be on a liquid diet or NPO

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the HCP if there is a rapid increase in which VS? A. Pulse B. Respirations C. BP D. Temperature

C Control of BP is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. VS are monitored, and BP is maintained as identified by the HCP and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other VS are important but the priority is to monitor blood pressure

Which activity should the nurse encouraage the client to avoid when there is a risk for increased ICP? A. Deep breathing B. Turning C. Coughing D. Passive ROM exercises

C Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck

A client is scheduled to receive phenytoin through a nasogastric tube and has a tube-feeding supplement running continuously. The head of the bed is elevated to 30 degrees. Prior to adminstering the medication, what should the nurse do? A. Elevate the head of the bed to 60 degrees B. Draw blood to determine the phenytoin level after giving the morning dose in order to determine if the client has toxic blood level C. Stop the tube feeding 1 hour before giving phenytoin, and hold tube feeding for 1 hour after giving the medication D. Flush the NGT with 150 mL of water before and after giving phenytoin

C In order for phenytoin to be properly absorbed and provide maximum benefit to the client, nutritional supplements must be stopped before and after delivery. The head of the bed is elevated 30 degrees since this client has a tuve feeding infusing; it is not necessary to elevate the bed any further. Blood levels are usually drawn before giving a dose of phenytoin, not after. If is not necessary to flush with such a large amount of water (150 mL) before and after administering phenytoin

A client has an increased ICP of 20. What should the nurse do next? A. Give the client a warming blanket B. Administer low-dose barbiturates C. Encourage the client to take deep breaths to hyperventilate D. Restrict fluids

C Normal ICP is 15 or less for 15-30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20. A cooling blanket is used to control the elvation of temperature because a fever increases ICP. High doses of barbituates may be used to reduce the increased cellular metabolic demands. Fluid colume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure >80.

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives TPA? A. Ask what medications the client is taking B. Complete a history and health assessment C. Identify the time of onset of the stroke D. Determine if the client is scheduled for any surgical procedures

C Studies show that clients who receive TPA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to TPA treatment is critical. A complete health assessment and history is mot possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of TPA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering TPA.

A client who has an open appendectomy for a perforated appendix has an incision secured with adhesive strips. What instructions should the nurse give the client about caring for the incision? A. Remove the adhesive strips to cleanse the area B. Cover the adhesive strips in place until they fall off C. Leave the adhesive strips in place until they fall off D. Place a plastic wrap over the incision when taking a bath

C The adhesive strips should stay in place until they fall off. The client should not remove them to cleanse the area. It is not necessary to place an additional dressing over the adhesive strips. The client should not take a tub bath until the incision has healed.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? A. Compress the nares B. Deceasing systolic BP C. Tachycardia D. Administer an antihistamine for postnasal drip

C The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important ot know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer antihistamine because the drainage may not be from postnasal drip

The nurse is assessing the LOC in a client with a head injury who has been unresponsive for the last 8 hours. Using the GCS, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do? A. Attempt to arouse the client B. Reposition the client with the extremities in normal alignment C. Chart the client's level of consciousness as coma D. Notify the HCP

C The client has a score of 6 (eye opening to pain = 2; verbal response, incomprehensible sounds = 2; best motor response, abnormal extension = 2; a score <7 is indicative of coma. While the nurse should continue to speka to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of limb extension. It is not necessary to notify HCP as this assessment doesn't represent a significant change in neurological status

When a client has an acute attack of diverticulitis, what should the nurse do first? A. Prepare the client for a colonoscopy B. Encourage the client to eat a high-fiber diet C. Assess the client for signs of peritonitis D. Encourage the client to drink a glass of water every 2 hours

C The nurse should first assess the client for signs of peritonitis. Complications of diverticulitis include perforation with peritonitis, abscess and fistula formation; bowel obstruction; ureteral obstruction; and bleeding. A CT scan with oral contrast is the test of choice for diverticulitis. A client with acute diverticulitis does not receive a barium enema or colonoscopy because of the possibility of peritonitis and perforation. With acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. The patient is kept on NPO status; parenteral fluid therapy is provided.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? A. Maintain a patent airway B. Record the seizure activity observed C. Ease the client to the floor D. Obtain VS

C, A, D, B To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airways since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and VS. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded

After instructing a client with diverticulosis about appropriate self-care activities, which comment by the client indicated effective teaching? Select all that apply. A. "With careful attention to my diet my diverticulosis can be cured" B. "Using a cathartic laxative weekly is okay to control bowel movement" C. "I should follow a diet that is high in fiber" D. "It is important for me to drink at least 2,000 mL of fluid every day" E. "I should exercise regularly"

C, D, E Clients who have diverticulosis should be isntructed to maintain a diet high in fiver and unless contraindicated, should increase their fluid intake to a maximum of 2,000 mL/day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; VS included temp 99 F, pulse 100 bpm, respirations of 18 breaths/min, and BP 140/70. The nurse should report which changes should they occur to the HCP? Select all that apply. A. Decreasing urinary output B. Decreasing systolic BP C. Bradycardia D. Widening pulse pressure E. Tachycardia F. Increasing diastolic BP

C. D The nurse should immediately report changes that indicate increasing ICP: Bradycardia, increasing systolic pressure, and widening pulse pressure. As ICP increases and the brain becomes more compressed, respiration become rapid, BP decreases, and the pulse slows further; these are very ominous signs. Decreased arterial BP and tachycardia can indicate bleeding elsewhere in the body. Decreasing urinary output indicates decreased tissue perfusion. The nurse monitors changes and notifies the HCP if trends continue.

A nurse is assessing a client with increasing intracranial pressure. What is a client's MAP when BP is 120/60?

80 MAP = systolic BP + (2 x diastolic BP) /3 MAP = 120 + (2x60) /3 MAP = 240/3=80

An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery? A. Place the client in semi-fowler's position with the knees to the chest B. Apply moist heat to the abdomen C. Teach client to massage the painful area D. Provide distraction with music

A Appendicitis typically begins with periumbillical pain followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing McBurney's point (located halfway between the umbilicus and the right iliac crest). To relive pain prior to surgery, the nurse assists the client to a comfortable position with the knees drawn to the chest and the head of the bed slightly elevated. The nurse may also administer analgesics and ice packs, if prescribed; heat is avoided as heat may precipitate rupture of the appendix. The abdomen is not palpated or massaged more than necessary to avoid increasing the pain. Distraction with music may be helpful, but positioning, using ice packs, and analgesics are most effective.

Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply. A. Bran cereal B. Broccoli C. Tomato juice D. Navy beans E. Cheese

A, B, D Clients with diverticulosis are encouraged to follow a high fiber diet. Beans, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods

The nurse administers mannitol to the client with increased ICP. Which parameters requires close monitoring? A. Muscle relaxation B. Intake and output C. Widening of the pulse pressure D. Pulse dilation

B After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decreased ICP

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A. Speaking loudly and slowly B. Using a "picture board" for the client to point to pictures C. Writing directions so the client can read them D. Speaking in short sentences

B Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client can point to objects or activities that he or she desires. Receptive aphasia is a condition in which the client doesn't comprehend what is being said. For this client, it is helpful to speak clearly using short sentences or writing out directions

Which respiratory pattern indicated increasing intracranial pressure in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest excursion D. Nasal flaring

A Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations, Rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia

A client with diverticular disease is receiving psyllium hydrophilic mucilloid. Which response from the client indicated to the nurse that the drug is having the intended effect? A. "I can pass stool without cramping" B. "I have occasional diarrhea" C. "My stool is firm" D. "I dont expel gas"

A Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophyllic mucilloid. Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives don't manage diarrhea or relieve gas formation. The stool should remain soft and easy to expel

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic BP C. Tachycardia D. Decreasing body temperature

A Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

The HCP prescribed intestinal decompression with a Cantor tube for a client with an intestinal obstruction. What should the nurse evaluate in order to determine the effectiveness of intestinal decompression? A. The intestinal fluid and gas have been removed B. The client has had a bowel movement C. The client's urinary output is adequate D. The client can sit up without pain

A Intestinal decompression is accomplished with a Cantor, or Miller-Abbott tube. These 6- to 10-foot tubes are passed into the small intestine to the obstruction. They remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to move easily to sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression.