MS Exam 3

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

A) Absence of reflexes along with flaccid extremities Feedback: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski reflex, hyperreflexia, and spasticity of all four extremities.

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer? A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel. B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state. C) Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing. D) The sudden, severe headache increases muscle tone and can cause further nerve damage.

A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel. Feedback: The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." B. "To detect and treat bradycardia, which is an excessively slow heart rate." C. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." D. "To shock your heart if you have a heart attack at home."

A. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." Rationale: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia.

The nurse is assessing a client with a spinal cord injury that reports a severe headache with a rapid onset. The nurse knows that this could be a symptom of which complication of a spinal cord injury? A. Autonomic dysreflexia B. Spinal shock C. Retinal hemorrhage D. Myocardial infarction

A. Autonomic dysreflexia Rationale: The client is likely suffering from an episode of autonomic dysreflexia which triggers an autonomic-hyper-response. Autonomic dysreflexia occurs after spinal shock, not due to it. Retinal hemorrhage and MI occur if autonomic dysreflexia is not resolved.

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this? A. Baclofen (Lioresal) B. Dexamethasone (Decadron) C. Mannitol (Osmitrol) D. Phenobarbital (Luminal)

A. Baclofen (Lioresal) Rationale: Baclofen is classified as an antispasmodic agent in the treatment of muscle spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in clients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A. Change the client's position frequently. B. Provide a high-protein diet. C. Provide light massage at least daily. D. Teach the client deep breathing and coughing exercises.

A. Change the client's position frequently. Rationale: Frequent position changes are among the best preventative measures against pressure ulcers. A high-protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage and deep breathing do not protect or restore skin integrity.

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? A. Check the client's indwelling urinary catheter for kinks to ensure patency. B. Lower the HOB to improve perfusion. C. Administer PRN analgesia as prescribed. D. Reassure the client that headaches are expected during recovery from spinal cord injuries.

A. Check the client's indwelling urinary catheter for kinks to ensure patency. Rationale: A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the client's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this client and is not expected.

The nurse is caring for a client who is in the recovery room following the implantation of an ICD. The client has developed ventricular tachycardia (VT). What should the nurse assess and document? A. ECG to compare time of onset of VT and onset of device's shock B. ECG so health care provider can see what type of dysrhythmia the client has C. Client's level of consciousness (LOC) at the time of the dysrhythmia D. Client's activity at time of dysrhythmia

A. ECG to compare time of onset of VT and onset of device's shock Rationale: If the client has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding

A. Fried chicken Rationale: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.

A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A. Have the client refrain from food and fluids after midnight. B. Administer the contrast agent orally 10 to 12 hours before the study. C. Administer the radioactive agent intravenously the evening before the study. D. Encourage the intake of 64 ounces of water 8 hours before the study.

A. Have the client refrain from food and fluids after midnight. Rationale: An ultrasound of the gallbladder is most accurate if the client fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo what intervention? A. Laparoscopic cholecystectomy B. Methyl tertiary butyl ether (MTBE) infusion C. Intracorporeal lithotripsy D. Extracorporeal shock wave therapy (ESWL)

A. Laparoscopic cholecystectomy Rationale: Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used. Cholecystectomy is the preferred treatment.

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B. Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C. A laparoscopic approach allows for the removal of the entire gallbladder. D. A laparoscopic approach can be performed under conscious sedation.

A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. Rationale: Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthesia in an operating theater.

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT D. Salt-wasting syndrome E. Increased ICP

A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT Rationale: For a spinal cord-injured client, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome and increased ICP are not typical complications following the immediate recovery period.

A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse's care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client? A. Pneumonia, pulmonary embolism, and sepsis B. Cardiac tamponade, hypoxia, and malnutrition C. Oxygen toxicity in paralytic ileus and electrolyte imbalances D. Seizures, osteomyelitis, and urinary tract infections

A. Pneumonia, pulmonary embolism, and sepsis Rationale: The nurse is assisting the client with assisted coughing to prevent pneumonia. Pulmonary infections are managed and prevented by frequent coughing, turning, and deep breathing exercises and chest physiotherapy; aggressive respiratory care and suctioning of the airway if a tracheostomy is present; assisted coughing as needed; and adequate hydration. Low-dose anticoagulation therapy usually is initiated to prevent DVT (deep vein thrombosis) and PE (pulmonary embolism), along with the use of anti-embolism stockings or sequential pneumatic compression devices (SCDs). Pressure injuries have the potential complication of sepsis, osteomyelitis, and fistulas. All of the other listed causes may occur in clients with SCI but are not the main causes of death. The interventions discussed above directly assist in the prevention of pneumonia, pulmonary embolism osteomyelitis and sepsis.

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of which condition? A. Pneumothorax B. Cardiac ischemia C. Acute bronchitis D. Aspiration

A. Pneumothorax Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, and aspiration.

Early signs of increased ICP include: SATA A) Behavioral changes B) Depression C) Mood Lability D) Changes in LOC (earliest sign) E) Depressive symptoms F) Pupillary changes G) Disorientation, restlessness H) Increased respiratory effort I) Constant headache slowly worsening J) Slow, bounding pulse K) Rapid, bounding pulse L) Weakness in one extremity/side of body

ALL BUT K

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complications B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress D. The client is likely experiencing an anaphylactic reaction to a medication

ANS: A Rationale: Airway obstruction caused by upper airway edema can take as long as 48hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury.

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A. "That's something that you and your doctor will likely talk about after your scarsmature." B. "That is something for you to talk to your doctor about because it's not a nursing responsibility." C. "I know this is really important to you, but you have to realize that no one can make you look like you used to." D. "Unfortunately, it's likely that these scars will look like this for the rest of your life."

ANS: A Rationale: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the client's query. It is true that the client will not realistically look like he or she used to, but this does not instill hope.

A client has been admitted to a burn intensive care unit with extensive full-thicknessburns over 25% of the body. After ensuring cardiopulmonary stability, what would be thenurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

ANS: A Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

ANS: A Rationale: During the early phase of burn care, the nurse is most concerned with fluidresuscitation, to correct large-volume fluid loss through the damaged skin. Infectioncontrol and early nutritional support are important, but fluid resuscitation is animmediate priority. Coping is a higher priority later in the recovery period.

A client presents at the walk-in clinic reporting diarrhea and vomiting. The client has a documented history of adrenal insufficiency. Considering the client's history and current symptoms, the nurse should anticipate that the client will be instructed to increase intake of: A. sodium. B. potassium. C. simple carbohydrates. D. calcium.

ANS: A Rationale: The client will need to supplement dietary intake with added salt during episodes of GI losses of fluid through vomiting and diarrhea to prevent the onset of addisonian crisis. While the client may experience the loss of other electrolytes, the major concern is the replacement of lost sodium.

A client who is in the acute phase of recovery from a burn injury has yet to experienceadequate pain control. What pain management strategy is most likely to meet this client's needs? A. A client-controlled analgesia (PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction and relaxation techniques supplemented by NSAIDs D. A combination of benzodiazepines and topical anesthetics

ANS: A Rationale: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the client.The use of client-controlled analgesia (PCA) gives control to the client and achieves this goal. Clients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family C. Treating infection D. Promoting thermoregulation

ANS: B Rationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.

A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? A. Oral temperature of 37.2°C (99°F) B. Tachypnea and restlessness C. Frequent loose stools D. Weight loss of 0.45 kg (1 lb) since yesterday

ANS: B Rationale: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 37.2°C (99°F) is not considered afever and would not be the first issue addressed.

The nurse's assessment of a client with thyroidectomy suggests tetany, and a review of the most recent blood work corroborates this finding. The nurse should prepare to administer what intervention? A. Oral calcium chloride and vitamin D B. IV calcium gluconate C. STAT levothyroxine D. Administration of parathyroid hormone (PTH)

ANS: B Rationale: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.

A client with severe burns is admitted to the intensive care unit to stabilize and beginfluid resuscitation before transport to the burn center. The nurse should monitor theclient closely for what signs of the onset of burn shock? A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation

ANS: C Rationale: As fluid loss continues and vascular volume decreases, cardiac outputcontinues to decrease and the blood pressure drops, marking the onset of burn shock.Shock and the accompanying hemodynamic changes are not normally accompanied byconfusion, fever, or agitation.

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal? A. Hyponatremia B. Hypophosphatemia C. Hypocalcemia D. Hypokalemia

ANS: C Rationale: Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the health care provider immediately because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia.

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A. Emergent B. Immediate resuscitative C. Acute D. Rehabilitation

ANS: C Rationale: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage.Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

. A client's burns are estimated at 36% of total body surface area; fluid resuscitationhas been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A. 0.45% NaCl with 20 mEq/L KCl B. 0.45% NaCl with 40 mEq/L KCl C. Normal saline D. Lactated Ringer

ANS: D Rationale: Fluid resuscitation with lactated Ringer (LR) should be initiated using theAmerican Burn Association's (ABA) fluid resuscitation formulas. LR is the crystalloid ofchoice because its composition and osmolality most closely resemble plasma andbecause use of normal saline is associated with hyperchloremic acidosis. Potassiumchloride solutions would exacerbate the hyperkalemia that occurs following burn injuries.

The nurse is caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote? A. Complete bed rest B. Bed rest with bathroom privileges C. Out of bed (OOB) to the chair twice a day D. Ambulation and activity as tolerated

ANS: D Rationale: Mobility, through walking or use of a rocking chair for those with limited mobility, is encouraged as much as possible because bones subjected to normal stress give up less calcium. Bed rest should be discouraged because it increases calcium excretion and the risk of renal calculi. Limiting the client to getting out of bed only a few times a day also increases calcium excretion and the associated risks.

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A. Maintenance of bed rest to aid healing B. Choosing appropriate splints and functional devices C. Administration of beta adrenergic blockers D. Prevention of venous thromboembolism

ANS: D Rationale: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

A client is admitted to a surgical unit after a thyroidectomy. The nurse takes and maintains the inflated blood pressure cuff on the client and observes a carpopedal spasm. What does this result indicate? A. Chvostek sign and hypocalcemia B. Thyroid storm and elevated triiodothyronine C. Homans sign and deep vein thrombosis D. Trousseau sign and overt tetany

ANS: D Rationale: The Trousseau sign is positive when carpopedal spasm (spasms of the hand or, less commonly, the feet) is induced by occluding the blood flow to the arm for 3 minutes and indicates tetany. Chvostek sign is positive when a sharp tapping over the facial nerve causes spasm, or twitching of the mouth, nose and eye. Chvostek sign also indicates tetany (neuronal excitability), which is usually associated with hypocalcemia. This result is not the product of a thyroid storm, which involves the excessive release of thyroid hormones given the client's surgery. Although blood pressure can be acquired on the leg; this is not the test for the Homans sign. A positive Homans sign is pain in the calf of the leg upon dorsiflexion of the foot and would suggest a deep vein thrombosis (DVT).

Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? • Peritonitis • Gastritis • Gastroesophageal reflux • Acute pancreatitis

Ans: A Feedback: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.

The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A) Respect the patients privacy during assessment. B) Shave all pubic hair for laboratory analysis. C) Place items for evidence in plastic bags. D) Bathe the patient before the examination.

Ans: A Feedback: The patients privacy and sensitivity must be respected, because the patient will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the patient before the examination would destroy or remove key evidence.

The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal? A) Encouraging the patient to gain a sense of control over his or her life B) Collecting sufficient evidence to secure a criminal conviction C) Helping the patient understand that this will not happen again D) Encouraging the patient to verbalize what happened during the assault

Ans: A Feedback:The goals of management are to provide support, to reduce the patients emotional trauma, and to gatheravailable evidence for possible legal proceedings. All of the interventions are aimed at encouraging thepatient to gain a sense of control over his or her life. The patients well-being should be considered apriority over criminal proceedings. No health professional can guarantee the patients future safety andhaving the patient verbalize the event is not a priority.

The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home? A)A humidification system B)An air conditioning system C)A water purification system D)A radiant heating system

Ans: A humidification system Feedback:The nurse stresses the importance of humidification at home and instructs the family to obtain and set up a humidification system before the patient returns home.

A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. A) Dysrhythmias B) Hypothermia C) Hypotension D) Hyperglycemia E) Delirium

Ans: A, C, E Feedback: The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.

A patient with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the patient's symptoms, the nurse should teach the patient to do which of the following? A)Eat a high-protein, low-carbohydrate diet. B)Avoid activities that cause an increased heart rate. C)Avoid large crowds and public events. D)Perform deep breathing and coughing exercises.

Ans: Avoid activities that cause an increased heart rate. Feedback:Patients with mitral stenosis are advised to avoid strenuous activities, competitive sports, and pregnancy, all of which increase heart rate. Infection prevention is important, but avoiding crowds is not usually necessary. Deep breathing and coughing are not likely to prevent exacerbations of symptoms and increased protein intake is not necessary.

A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis

Ans: B Feedback: The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? • The patient has abdominal bloating that developed rapidly. • The patient has a rigid, boardlike abdomen that is tender. • The patient is experiencing intense lower right quadrant pain. • The patient is experiencing dizziness and confusion with no apparent hemodynamic changes.

Ans: B Feedback:An extremely tender and rigid (boardlike) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer.

A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Ascites B) Rebound tenderness C) Changes in bowel sounds D) Muscular rigidity E) Copious diarrhea

Ans: B, C, D Feedback:Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

An older adult patient has been diagnosed with aortic regurgitation. What change in blood flow should the nurse expect to see on this patient's echocardiogram? A)Blood to flow back from the aorta to the left ventricle B)Obstruction of blood flow from the left ventricle C)Blood to flow back from the left atrium to the left ventricle D)Obstruction of blood from the left atrium to left ventricle

Ans: Blood to flow back from the aorta to the left ventricle Feedback:Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of blood from the left atrium to left ventricle.

A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the patients care? A. Ablate the area causing the dysrhythmia. B. Freeze hypersensitive cells. C. Diagnose the dysrhythmia. D. Determine the nursing plan of care.

Ans: C Feedback:A patient may undergo an EP study in which electrodes are placed inside the heart to obtain an intracardiac ECG. This is used not only to diagnose the dysrhythmia but also to determine the most effective treatment plan. However, because an EP study is invasive, it is performed in the hospital and may require that the patient be admitted.

The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient states that she is nervous about things going wrong during the procedure. What is the nurses best response?A. This is basically a risk-free procedure. B. Thousands of patients undergo EP every year. C. Remember that this is a step that will bring you closer to enjoying good health. D. The whole team will be monitoring you very closely for the entire procedure.

Ans: D Feedback:Patients who are to undergo an EP study may be anxious about the procedure and its outcome. A detailed discussion involving the patient, the family, and the electrophysiologist usually occurs to ensure that the patient can give informed consent and to reduce the patients anxiety about the procedure. It is inaccurate to state that EP is risk-free and stating that it is common does not necessarily relieve the patients anxiety. Characterizing EP as a step toward good health does not directly address the patients anxiety.

A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that thepatient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rapetrauma syndrome is this patient most likely experiencing? A) Reorganization phase B) Denial phase C) Heightened anxiety phase D) Acute disorganization phase

Ans: D Feedback:The acute disorganization phase may manifest as an expressed state in which shock, disbelief, fear, guilt,humiliation, anger, and other such emotions are encountered. These varied responses to the assault arenot associated with a denial, heightened anxiety, or reorganization phase.

A patient's total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process? A)Training on how to perform controlled belching B)Use of an electronically enhanced artificial pharynx C)Insertion of a specialized nasogastric tube D)Fitting for a voice prosthesis

Ans: Fitting for a voice prosthesis Feedback:In patients receiving transesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom-Singer®) is fitted over the puncture site.

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A)Anxiety related to diagnosis of cancer B)Altered nutrition related to swallowing difficulties C)Ineffective airway clearance related to airway alterations D)Impaired verbal communication related to removal of the larynx

Ans: Ineffective airway clearance related to airway alterations Feedback:Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk? A)Facilitate total parenteral nutrition (TPN). B)Keep a complete suction setup at the bedside. C)Feed the patient several small meals daily. D)Refer the patient for occupational therapy.

Ans: Keep a complete suction setup at the bedside. Feedback:Due to the risk for aspiration, the nurse keeps a suction setup available in the hospital and instructs the family to do so at home for use if needed. TPN is not indicated and small meals do not necessarily reduce the risk of aspiration. Physical therapists do not address swallowing ability.

The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic regurgitation causes what? A)Cardiac tamponade B)Left ventricular hypertrophy C)Right-sided heart failure D)Ventricular insufficiency

Ans: Left ventricular hypertrophy Feedback:Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood from the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. Aortic regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular insufficiency.

A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension. What valvular disorder should the nurse anticipate being diagnosed in this patient?A)Aortic regurgitation B)Mitral stenosis C)Mitral valve prolapse D)Aortic stenosis

Ans: Mitral stenosis Feedback:The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its usual size. Patients are likely to show progressive fatigue as a result of low cardiac output. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Patients may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections. Pulmonary venous hypertension is not typically caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis.

The nurse is caring for a patient with right ventricular hypertrophy and consequently decreased right ventricular function. What valvular disorder may have contributed to this patient's diagnosis? A)Mitral valve regurgitation B)Aortic stenosis C)Aortic regurgitation D)Mitral valve stenosis

Ans: Mitral valve stenosis Feedback:Because no valve protects the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. As a result, the right ventricle must contract against an abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right ventricle fails. None of the other listed valvular disorders has this pathophysiological effect.

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? A)Monitor liver function studies B)Monitor for hypotension C)Assess the patient's vitamin D intake D)Assess the patient for hyperkalemia

Ans: Monitor for hypotension Feedback: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development? A)Remove the patient's drain and apply pressure with a sterile gauze. B)Assess the patient, reposition the patient supine, and apply wall suction to the drain. C)Rapidly assess the patient and notify the surgeon about the patient's bleeding. D)Administer a STAT dose of vitamin K to aid coagulation

Ans: Rapidly assess the patient and notify the surgeon about the patient's bleeding. Feedback:The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea.

A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following? A)The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) B)The need to learn to sleep in a semi-Fowler's position for the first 6 to 8 weeks to prevent emboli C)The need to avoid foods that contain vitamin K D)The need to take enteric-coated ASA on a daily basis

Ans: The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) Feedback:Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.

The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of a laryngeal communication will likely be chosen? A)Esophageal speech B)Electric larynx C)Tracheoesophageal puncture D)American sign language (ASL)

Ans: Tracheoesophageal puncture Feedback: Tracheoesophageal puncture is simple and has few complications.

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased? A. Magnetic resonance imaging (MRI) B. Electroencephalography (EEG) C. Electromyography (EMG) D. Computed tomography (CT)

B Rationale: The EEG can be used to determine that brain activity has ceased.. MRI and CT scans have been used to declare brain death by showing an absence of blood flow, but this is not the best way to determine that brain activity has ceased. EMG is not normally used to determine brain death.

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patients initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patients fluid balance C) Assessing the patients level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

B) Maintaining and monitoring the patients fluid balance Rationale:In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitorthe patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority

A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a correct understanding of this medication? A. "This drug may make my heart beat slower." B. "This drug is particularly good at preventing asthma attacks during exercise." C. "I'll make sure to use this each time I feel an asthma attack coming on." D. "I understand that this drug is less effective at controlling night-time symptoms."

B. "This drug is particularly good at preventing asthma attacks during exercise."

A nurse is assigned four clients with diagnoses that rule out myocardial infarction (MI) due to chest pain. Which client's test results best demonstrate the specific diagnosis of unstable angina (USA)? A. A 63-year-old client with elevated troponins and no elevation in the ST segment. B. A 72-year-old client with an increase in myoglobin, no elevation in the STsegment, and no elevation in troponins. C. A 54-year-old client with elevated creatine kinase myocardial band (CK-MB) andST segment elevations in two contiguous leads on the electrocardiogram (ECG). D. A 48-year-old client with T wave inversions, ST elevation, and abnormal Qwaves.

B. A 72-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponin. Rationale: The 72-year-old client with chest pain had clinical manifestations of coronary ischemia, but the ECG showed no evidence of an acute MI. The 72-year-old client had an elevated myoglobin, which is a biomarker but is not a very specific indicator of a cardiac event because an elevation may also occur due to seizures, muscle diseases, trauma, and surgery. The 63-year-old client had test results consistent with a non-ST-elevated myocardial infarction: elevated cardiac biomarkers but no ECG evidence of an acute MI.The 48- and 54-year-old clients had test results consistent with an ST-elevated myocardial infarction: elevated cardiac biomarkers, ECG changes in two contiguous leads, ST elevation, and Q wave abnormalities

A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as prescribed B. Application of heat 15 to 20 minutes each hour C. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area

B. Application of heat 15 to 20 minutes each hour Rationale: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding.

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? A. Respiratory distress and projectile vomiting B. Bradycardia and hypertension C. Tachycardia and agitation D. Third-spacing and hyperthermia

B. Bradycardia and hypertension Rationale: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client? A. Seizure prophylaxis and prevention B. Cervical and spinal immobilization C. Fluid and electrolyte maintenance, D. Intubation and mechanical ventilation

B. Cervical and spinal immobilization Rationale: Any client with a head injury is presumed to have a cervical spine injury until proven otherwise. The client is transported from the scene of the injury on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained and the absence of cervical SCI (spinal cord injury) documented. This client's x-rays were pending so spinal precautions should be maintained and are the priority. Primary injury to the brain is defined as the consequence of direct contact to the head/brain during the instant of initial injury, causing extracranial focal injuries. The greatest opportunity for decreasing TBI (traumatic brain injury) is the implementation of prevention strategies. Treatment for clients with suspected increased intracranial pressure (ICP) also includes ventilator support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and management of pain and anxiety. Clients who are comatose are intubated and mechanically ventilated to ensure adequate oxygenation and to protect their airway. No information was provided on current ICP. The client was not fully orientated so he/she was transferred to the ICU for closer monitoring.

An asthma educator is teaching a client newly diagnosed with asthma and the family about the use of a peak flow meter. The educator should teach the client that a peak flow meter measures highest airflow during which type of breath? A. Forced inspiration B. Forced expiration C. Normal inspiration D. Normal expiration

B. Forced expiration

Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A. Complete the pin site care to decrease risk of infection. B. Notify the neurosurgeon of the occurrence. C. Stabilize the head in a lateral position. D. Reattach the pin to prevent further head trauma.

B. Notify the neurosurgeon of the occurrence. Rationale: If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Prepare to transfuse packed red blood cells. B. Prepare for interventions to increase the client's BP. C. Place the client in the Trendelenburg position. D. Prepare an ice bath to lower core body temperature.

B. Prepare for interventions to increase the client's BP. Rationale: Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 11/2 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A. Risk for impaired skin integrity B. Risk for injury C. Risk for autonomic dysreflexia D. Risk for suffocation

B. Risk for injury Rationale: If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the client's neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is not a primary concern. Intubation does not carry the potential to cause suffocation.

The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the client. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A. P-wave inversion B. T-wave inversion C. Qwave changes with no change in ST or T wave D. P-wave enlargement

B. T-wave inversion Rationale: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

The pathophysiology of hypoparathyroidism is associated with all of the following except: a. a decrease in serum calcium. b. an elevation of blood phosphate. c. an increase in the renal excretion of phosphate. d. a lowered renal excretion of calcium.

C

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

C Rationale: Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day

C) Initiating (ROM) exercises as soon as possible after the injury Feedback: Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures.

A school nurse is caring for a 10-year-old client who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? A. Administer corticosteroids by metered dose inhaler. B. Administer inhaled anticholinergics. C. Administer an inhaled beta-adrenergic agonist. D. Use a peak flow monitoring device.

C. Administer an inhaled beta-adrenergic agonist.

The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, which condition is a potential primary cause of the client's heart failure? A. Endocarditis B. Pleural effusion C. Atherosclerosis D. Atrial septal defect

C. Atherosclerosis Rationale: Atherosclerosis of the coronary arteries is the primary cause of heart failure. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of heart failure.

An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A. PP interval and RR interval are irregular. B. PP interval is equal to RR interval. C. Fewer QRS complexes than P waves D. PR interval is constant.

C. Fewer QRS complexes than P waves Rationale: In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes are not consistent with this diagnosis.

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A. Limit the amount of assistance provided with ADLs. B. Collaborate with the physical therapist and immobilize the client's extremities temporarily. C. Increase the frequency of ROM exercises. D. Educate the client about the importance of frequent position changes.

C. Increase the frequency of ROM exercises. Rationale: To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? A. Risk for impaired skin integrity related to immobility and sensory loss B. Impaired physical mobility related to loss of motor function C. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously

C. Ineffective breathing patterns related to weakness of the intercostal muscles Rationale: A nursing diagnosis related to breathing pattern would be the priority for this client. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. High-fiber foods B. Low-purine, nutrient-dense foods C. Low-fat foods high in proteins and carbohydrates D. Foods that are low-residue and low in fat

C. Low-fat foods high in proteins and carbohydrates Rationale: The nurse encourages the client to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. There is no specific need to increase fiber or avoid purines. A low-residue diet is not indicated.

A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention? A. Insertion of an intracranial monitoring device B. Treatment with antihypertensives C. Making openings in the skull D. Administration of anticoagulant therapy

C. Making openings in the skull Rationale: An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be prescribed for a client who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this client.

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A. Position the client in a high-Fowler position when in bed. B. Support the knees with a pillow when the client is in bed. C. Perform passive ROM exercises as prescribed. D. Administer NSAIDs as prescribed.

C. Perform passive ROM exercises as prescribed. Rationale: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the client's risk of muscle spasticity.

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? A. Management of fluid balance in the home setting B. The need for blood glucose monitoring for the next week C. Signs and symptoms of intra-abdominal complications D. Appropriate use of prescribed pancreatic enzymes

C. Signs and symptoms of intra-abdominal complications Rationale: Because of the early discharge following laparoscopic cholecystectomy, the client needs thorough education in the signs and symptoms of complications. Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. There is no need for blood glucose monitoring or pancreatic enzymes.

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Epidural hemorrhage B. Hypertensive emergency C. Spinal shock D. Hypovolemia

C. Spinal shock Rationale: In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed and dilated. What is the most plausible clinical significance of the nurses finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.

D Rationale: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.

D Rationale: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as prescribed C. Vitamin B12 injections as prescribed D. Administration of diuretics as prescribed

D. Administration of diuretics as prescribed Rationale: Use of diuretics along with sodium restriction is successful in 90% of clients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery? A. Diabetic coma B. Decubitus ulcer C. Wound evisceration D. Bile duct injury

D. Bile duct injury Rationale: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Clients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what event? A. Syncope (fainting) B. Suicide attempts C. Workplace injuries D. Motor vehicle accidents

D. Motor vehicle accidents Rationale: The most common causes of SCIs are motor vehicle crashes, falls, violence, and sports.

The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge? A. Walk 1 mile (1.6 km) 3 to 4 times a week. B. Use weights daily to increase arm strength. C. Walk on a treadmill 30 minutes daily. D. Perform shoulder exercises five times daily.

D. Perform shoulder exercises five times daily. Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the client on the importance of performing shoulder exercises five times daily. The client should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A. Inability to use a wheelchair B. Unable to swallow liquid and solid food C. Incontinent in bowel movements D. Requires full assistance for elimination

D. Requires full assistance for elimination Rationale: Clients with a lesion at C4 are fully dependent for elimination. The client is dependent for feeding, but is able to swallow. The client will be capable of using an electric wheelchair.

The nurse is caring for a client who has been in a motor vehicle accident and is suspected of having developed pleurisy. Which assessment finding would best corroborate this diagnosis? A. The client is experiencing painless hemoptysis. B. The client's arterial blood gases (ABGs) are normal, but the client demonstrates increased work of breathing. C. The client's oxygen saturation level is below 88%, but the client denies shortness of breath. D. The client's pain intensifies when the client coughs or takes a deep breath.

D. The client's pain intensifies when the client coughs or takes a deep breath. Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking adeep breath, coughing, or sneezing worsens the pain. The client's ABGs would most likely beabnormal, and shortness of breath would be expected. Painless hemoptysis is not characteristic ofpleurisy.

Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. When should the nurse remove and reapply the splints? A. At the client's request B. Each morning and evening C. Every 2 hours D. One hour prior to mobility exercises

C. Every 2 hours Rationale: The feet are prone to foot drop; therefore, various types of splints are used to prevent foot drop. When used, the splints are removed and reapplied every 2 hours.

A nurse in a busy emergency department provides care for many clients who presentwith contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. A. Massage B. Applying ice C. Compression dressings D. Resting the affected extremity E. Corticosteroids F. Elevating the injured limb

ANS: B, C, D, F Rationale: Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response?

"The difference is the timing of the delivery of the electric current."

A diagnosis of hyperparathyroidism can be established by all of the following signs except a. a negative reading on a Sulkowitch test. b. a serum calcium level of 12 mg/dL. c. an elevated level of parathyroid hormone. d. bone demineralization seen on an x-ray film.

A

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

A) Disorientation and restlessness Feedback: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? A. Increased potassium intake B. Fluid restriction to 2 L per day C. Reduction in sodium intake D. High-protein, low-fat diet

C. Reduction in sodium intake Rationale: Clients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.

A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A) Hemiplegia B) Dry mucous membranes C) Signs of internal bleeding D) Loss of brain stem reflexes

D Rationale: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion. B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.

D. The client's urinary catheter became occluded. Rationale: A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in medications or blood transfusions are unlikely causes.

Hypocalcemia is associated with which of the following manifestations?

Muscle twitching

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?

Older adults often lack the classic signs and symptoms of pneumonia.

Spironolactone

Potassium-sparing diuretics such as spironolactone are used to treat ascites.

Intraperitoneal Injury

The abdomen is assessed for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing distention, and pain. Referred pain is a significant finding because it suggests intraperitoneal injury.