Nclex '24

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns form surgery?

Obturator

how much of a size difference between the two pupils is still considered normal?

1 mm

The nurse provides teaching to the parents of an adolescent client. The client's diagnosis is generalized anxiety disorder. Which statements by the nurse are included in the teaching: -This is a rare mental health disorder that affects a small part of the population -If the anxiety is unresolved, the sense of fear can affect the activities of daily living -if your child's moderate anxiety is left untreated, it can progress to an anxiety disorder -your child's brain chemistry may be a contributing cause of their anxiety disorder -evidence shows that a genetic association is present with anxiety disorders

-If the anxiety is unresolved, the sense of fear can affect the activities of daily living -if your child's moderate anxiety is left untreated, it can progress to an anxiety disorder -your child's brain chemistry may be a contributing cause of their anxiety disorder -evidence shows that a genetic association is present with anxiety disorders

The nurse is providing care for a 2-month-old infant scheduled for a pyloromyotomy. Which of the following pre-operative actions can the nurse expect to perform? SATA -Allow breastfeeding 1 hr before surgery -Review coagulation study results -avoid all pre-operative sedation -keep NPO as ordered before surgery -Begin IV fluids at maintanence -Place NG tube to low suction

-Keep NPO as ordered -Begin IV fluids at maintanence rate -Place NG tube to low suction

The nurse is preparing to suction an adult client through the client's tracheostomy tube. which interventions should the nurse perform for this procedure. SATA -apply suction for up to 10 to 15 seconds -hyperoxygenate the client before suctioning -set the wall suction unit pressure at 160 mmHg -apply suction while gently inserting the catheter -apply intermittent suction while rotating and withdrawing the catheter -advance the catheter until resistance is met and then pull the catheter back 1 cm

-hyperoxygenate the client before suctioning -set the wall suction unit pressure at 160 mmHg -apply suction while gently inserting the catheter -apply intermittent suction while rotating and withdrawing the catheter -advance the catheter until resistance is met and then pull the catheter back 1 cm

The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure?

1. semi-fowlers

Thie nurse is planning to suction a client through a tracheostomy tube. which is the amount of time for application of suction during withdrawal of the catheter?

10 seconds

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow coma scale (GCS) should the nurse document? Record a whole number

3

The nurse uses the Glascow Coma Scale to assess a client with a head injury. Which glascow coma scale score indicates that the client is in a coma?

6

A client has mean arterial blood pressure (MAP) of 97 mm Hg and an intracranial pressure of 12 mm Hg. What is the cerebral perfusion pressure? Record your answer using a whole number

85

Highlight the findings that are recognized as needing only standard precautions: The client reports pain level 9/10 upper abdominal discomfort for the last week. He reports watery diarrhea for the past 3 days for 8 times a day. Assessment includes: lung sounds without adventitious sounds; heart rhythm regular with S1 and S2; capillary refill at +2 sec; equal grips; a + o x4, visible jaundice. Client reports HIV positive for 3 years. WBC count down with results of 1,000

9/10 upper abdominal discomfort, lung sounds without adventitious sounds, visible jaundice

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding?

Absence of breath sounds on auscultation

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs when suctioning

The nurse cares for 4 clients. Which activity demonstrates the nurse's understanding of how ethnicity influences the client's health?

Assess a 5 month old African American client for sickle cell anemia

The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of the suctioning?

Breath sounds are clear

The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator of the effectiveness of suctioning?

Breath sounds are now clear

The nurse explains to the client that the cast removal will be completed by __________. The client reports pruritus following removal of the cast, and the nurse ________________.

Cutting it open with a cast saw and applies emollient lotion to the arm

Embryos that are produced by in vitro fertilization can be screened for genetic disease. Outline the process of in vitro fertilization, including one examples of a situation when it is used. Extended response:

Drugs used to down-regulate the menstrual cycle; HCG injected to cause the follicles to mature; eggs are harvested/extracted ; semen collected; sperm directly injected into egg; healthiest embryo chosen, used for low sperm count, infertility etc

The nurse reviews the nurse' notes from 1300, 1500, 2000 and 2020. Based on the information, which is the priority action by the nurse?

Ensure that endotracheal intubation is ready at the bedside

The nurse cares for a newborn. The nurse notes small, pimple-like pustules all over the newborn's body, as seen in the image. When charting the integumentary assessment of this newborn, which normal finding does the nurse note?

Erythema Toxicum

PT levels = 1.3-2.1 m EQ=q/L True or false?

False

The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema?

Frothy Sputum

A patient who is recieving treatment for Varicella, asks for assistance to the bathroom. Before entering the room, you must don personal protective equipment. Organize the correct sequence in how you will don personal equipment. Organize the correct sequence in how you will don personal protective equipment.

Hand hygiene, mask, protective, gloves

The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?

Hypotension

Which findings are typical of end-stage renal disease? SATA Iron-deficient Anemia Increased Albumin levels Decreased creatinine clearance Metabolic acidosis Increased serum calcium Respiratory Alkalosis

Iron-deficient Anemia Decreased Creatinine Metabolic Acidosis

A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour?

Lorazepam (ativan)

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take?

Monitor vital signs and discontinue attempts at suctioning until the client is stabilized

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic syndrome (SIADH). The nurse will expect to see which clinical findings upon assessment? SATA -Nausea and vomitting -Hyperthermia -Bradycardia -increased weight -decreased serum sodium -decreased level of consciousness

Nausea and vomiting, increased weight, decreased serum sodium, decreased level of consciousness

Highlight the 6 findings that show improvement in the client's condition and/or adherence to treatment recommendations

No pain is reported in the left arm, no longer needing to take any analgesic medications, no edema present, radial and ulnar pulses 2+ bilaterally. Capillary refill 2 sec.

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after supraglottic laryngectomy. The licensed practical nurse should perform which action?

Notify the RN

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the ABG reports for which results that are consistent with this disorder?

PaO2 49mm Hg, PacO2 52 mm Hg

The nurse cares for an older adult client with congestive heart failure following a myocardial infarction. The client reports having difficulty breathing and states, "I feel as if Im drowning when I lie down." Which complication does the nurse recognize as contributing to this assessment finding?

Pulmonary edema

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

Quality of respirations and presence of pulses

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response?

Respiratory paralysis and cessation of diaphragmatic contractions

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the RN?

Stridor

A client is scheduled for a computed tomography (CT) of the brain with contrast. When reviewing the client's medical record, what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure?

The client takes metformin daily

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? SATA -Cortisol -Thyroid -Estrogen -Testoterone

Thyroid and Testoterone

After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?

Tubular reabsorption of water increases

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but it is unable to do so. Which would be the next immediate nursing action?

Ventilate the client with a resuscitation bag

The nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which is done as a final measure to determine correct tube placement?

Verify placement by a chest x-ray

Case study select the 4 findings that require immediate follow up?

Vital signs, lungs sounds, radial pulse characteristics, characteristics of the cough

which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

Yellow

Outline the process of speciation:

a. speciation is the splitting of a species «into two species» b. reproductive isolation/lack of interbreeding c. isolation due to geography/«reproductive» behavior/«reproductive» timing d. polyploidy can cause isolation e. gene pools separated f. differences in/disruptive selection cause traits/gene pools to change/diverge g. gradualism / speciation/changes accumulating over long periods h. punctuated equilibrium / speciation/changes over a short time period

Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation?

black

a client is admitted with head trauma after a fall. The client is being prepared for supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication is primarily given to do what?

decrease fluid in the brain

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

disconnect suction source from the catheter

The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? SATA -nose blowing -teeth brushing -bending forward -breathing through mouth -lying semi-fowlers

nose blowing, teeth brushing, bending forward

The nurse is providing post procedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take?

notify the primary care provider immediately

actions to take and parameters to monitor for physiologic jaundice?

offer formula supplementation and call provider, monitor intake and output and serum bilirubin

The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status?

respiratory rate of 18

The nurse provides education during the discharge of a client who has a diagnosis of multiple sclerosis. Which priority statement does the nurse include in the teaching?

schedule the occupational therapist to do a safety assessment of your home

The nurse is assigned to care for a client after a left pneumonectomy. which position is contraindicated for this client?

Lateral position

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?

suction the client

Explain, using an example, how females but not males can be carriers of some recessive alleles. Extended response

Females are carriers when they have dominant and recessive alleles together; recessive allele in carrier does not affect phenotype as dominant allele present. Gene is located on the X chromosome; haemophilia color blindness is a sex linked characterisitcs

The nurse is teaching the parent of an infant client about common pediatric conditions. Which statement by the nurse about otitis media is correct?

Otitis media usually occurs before your child experiences a primary bacterial infection

The nurse is caring for a client at home who has had a tracheostomy tube for several months. the nurse monitors the client for complications associated with the long term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client?

abdominal distention

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia?

hypertension and bradycardia

A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP?

unequal pupil size

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? SATA -vomiting -irritability -hypotension -increased respirations -decreased level of consciousness

vomiting, irritability, decreased level of consciousness

An oval pupil is indicative of

intracranial hypertension

Which type of ICP monitoring device has the most accurate ICP measurement and provides access to CSF for sampling?

intraventricular catheter

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolality is what?

sodium

The nurse will use contact ___________________ precautions when providing care to this client because _________________.

standard precautions, is not contagious

a client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. which is the nurse's priority intervention?

check the client for spontaneous breathing

The most clinically significant ICP waveform is

A waves

One of the earliest and most important signs of increased ICP is

a decrease in the level of consciousness

The GCS is an invalid measure for the patient with

intoxication

signs and symptoms associated with a flail chest include

paradoxical respiratory movement

a patient with multisystem trauma has been in the ICU for 6 days after sustaining a closed head injury, a right-sided pneumothorax, right rib fractures, a grade IV liver laceration, a pancreatic contusion, and a right acetabular fracture. The patient is still intubated mechanically ventilated and has a chest tube, foley catheter, and two abdominal drains. The patients hemodynamic assessment reveals the following values: BP 94/66, HR 118, T 38.7, CVP 5 cm, cardiac index 6.1 and systemic vascular resistance, 450 dynes/sec. What is the most likely cause of the hemodynamic picture?

septic shock

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?

stop the procedure and oxygenate the client

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement?

stop the suctioning

Institutional ethics committees review ethical cases that are problematic for the practitioner. Major functions of IECs include

support and education to health care providers

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left and decreased breath sounds on the right side. What is the most likely diagnosis?

tension pneumothorax

The target range for PaCO2 when using hyperventilation to lower ICP.

35>

Which of the following patients may need sedation before having an MRI scan?

claustrophobic patient

According to the 2007 Brain trauma foundation guidelines, the recommended CPP range is

50-70 mm Hg

Institutional ethics committees review ethical cases that are problematic for the practitioner. Major functions of IECs include

???

The patient is ordered a CT scan without contrast. Which question should the nurse ask the conscious patient before the procedure?

Are you allergic to iodine-based dye?

A score of 6 on the Glascow coma scale indicates

coma

A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. Based on which ethical principles does the nurse answer the patient's questions?

Autonomy

a patient is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?

BP 90/70 mm Hg, HR 140, HCT 21 mg/dL, UO 10 mL/hr, pale, cool, clammy skin, confused

Which intervention should be considered LAST in treating uncontrolled intracranial hypertension?

Barbiturates

Decerebrate posturing (abnormal extension) indicates dysfunction in which area of the central nervous system?

Brainstem

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?

coughing occurs with suctioning

Four clients who sustained head injuries are presented below. Which client has the least score on the Glascow coma scale? -A: able to open eyes spontaneously, localize pain and able to respond to verbal commands -B: able to open eyes to sound, sensation and localized pain, conversation is confused -C: Able to open eye to pain stimulus, has normal flexion and an inappropriate verbal response -D: able to open eye to pain stimulus, localizes pain, but has confused verbal response

Client C

The nurse is performing nasotracheal suctioning of a client. the nurse interprets that the client is adequately tolerating the procedure if which observation is made?

coughing occurs with suctioning

Which of the following independent nursing measures can assist in reducing increased ICP?

Decreasing noxious stimuli

Outline the various stages of the cell cycle.

G1 the cell grows/duplication of organelles; S is synthesis stage when DNA is synthesized/replicated; G2 the chromosomes begin condensing/preparation for cell division; G1 , S and G2 make up interphase; during mitosis nuclear division occurs/all four stages listed; during cytokinesis cytoplasm/cell divides/daughter cells formed;

Which patient position is optimal to prevent elevated ICP pressures?

Individualized head position to maximize cerebral perfusion pressure and minimize ICP measurements

Which of the following denotes the most serious prognosis?

decerebrate posturing

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which functions will the nurse assess? SATA -Balance -breathing -pulse rate -fat metabolism -temperature regulation

breathing and pulse rate

Studies have shown that the intraparenchymal catheter has a better result than the intraventricular catheter. Identify the answer that supports this statement

The intraparenchymal catheter has decreased device-related complications

A patient becomes flaccid with fixed and dilated pupils. The patient's ICP falls from 65 to 12 mm Hg. What should the nurse expect is happening?

The patient's brain has herniated

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement?

check the amount of suction pressure being applied

The nurse is assisting in caring for the client with a tracheal tube attached to a ventilator when the high pressure alarm sounds. The nurse checks the client and system for which most likely cause?

accumulation of secretions in the clients lungs

a patient's ICP is 34 mm Hg and his cerebral perfusion pressure is 65 mm Hg. Which of the following is the most appropriate intervention?

administer mannitol 1 to 2 g/kg IV

a patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Caring for the patient would include which of the following interventions?

administering IV methylprenisolone for the first 24 hrs after the injury

a patient was thrown 30 feet from an open-top jeep and straddled a row of mailboxes before she landed on the ground. she has an open pelvic fracture. The nurse is admitting the patient into the ICU knows that

aggressive fluid and blood replacement will probably be needed

When opening the airway of an unresponsive trauma patient in the emergency department, which of the following considerations is correct?

airway assessment must incorporate cervical spine immobilization

In the ethical decision-making process, after the identification of alternative options has been established:

an outcome for each action must be predicted

When deciding whether to withdraw or withhold treat, it is important to:

approach the family with honesty and provide clear information

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?

assess the client's airway

A nurse is caring for a client who sustained a transection of the spinal cord with no injuries. The nurse continually monitors this client for which medical emergency?

autonomic dysreflexia

A nurse is caring for a client with a spinal cord injury during the immediate post injury period. Which is the priority focus of nursing care during this immediate phase?

avoiding flexion or hypertension of the spine

A nurse observes a window washer falling 25 feet to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

begin chest compressions

The Lab reports of a client who underwent a hypophysectomy show an intracranial pressure of 20 mmHg. Which action made by the client is responsible for this condition?

bending over at the waist

The nursing care plan of a patient with a diffuse axonal injury (DAI) would involve which of the considerations?

blood pressure and temperature elevations are common

The clinical manifestations of the cushing reflex are

bradycardia, systolic hypertension, and widening pulse pressure

The most serious complication of lumbar puncture in a critically ill patient is

brainstem herniation

a patient is admitted to the critical care unit with a subdural hematoma. The GCS is used to assess his level of consciousnes. In assessing the patient's best motor response, the movement that receives the lowest score is

decerebrate posturing

MRI is superior to CT for which of the following?

detection of central nervous system infection

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take?

discontinue suctioning until the client is stabilized and monitor vitals

the nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. the nurse should provide the client with which information about his type of tube?

enables the client to speak

the nurse assess a client at 40 weeks gestation and notes regular contractions and cervical dilation of 6 cm. Which actions by the nurse are important during this stage?SATA -Adminstering epidural injection -ensuring adequate hydrations -encouraging the client to void -monitoring the condition of the fetus -staying at the bedside until the client delivers

ensuring adequate hydrations, monitoring the conditions of the fetus, encouraging client to void

A strategy to minimize secondary brain injury in head-injured patients is

fluid resuscitation as needed to keep the systolic blood pressure greater than 90 mm hg

A critical care patient is diagnosed with massive trauma. The patient is receiving brain tissue oxygen pressure monitoring. The nurse that the treatment is to maintain PbtO2.

greater than 20 mmHg

Which of the following is the most common complication after high-dose barbiturate therapy?

hypotension

a client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?

inadequate antidiuretic hormone (ADH) secretion

Initially after a brain attack (stroke, CVA) a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. on which condition should the nurse be prepared to focus care?

increased intracranial pressure

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?

increasing intracranial pressure

a client who sustained a closed head injury is being monitored increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is the most important for the nurse to take?

inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure

Click to highlight below the 3 orders that nurse should perform right away: Insert an indwelling chatheter, CT scan of the chest, 0.9% NS 500 mL, Laboratory tests; blood cultures

insert an indwelling urinary catheter, 0.9% NS 500 mL, Laboratory tests; blood cultures

A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? SATA -irritability -bradycardia -hyperalertness -decreased pulse pressure -decreased systolic blood pressure

irritability, bradycardia

The most important aspect of the neurologic examination is

level of consciousness

The nurse identifies ______________ and ___________ as abnormal findings which require follow up.

localized edema and pain

The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observation by the nurse is inconsistent with the need for suctioning?

low peak inspiratory pressure on the ventilator

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

lowered level of consciousness

A client who was in a monitor bike accident has a severe neck injury. Which priority nursing care is most needed?

maintaining a patent airway

The osmotic diuretic that has been most effective in the reduction of increased ICP is

mannitol

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

monitor the client for signs of brain injury

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?

monitoring the client for increasing intracranial pressure

A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. the nurse conflicting emotions about how to handle the situation and is experiencing:

moral distress

The patient patient's ICP reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to

notify the physician

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

pH of 7.48, PCO2 of 40mm Hg, HCO3 of 36 mEq/L

All organisms in an ecosystem are involved in the carbon cycle. outline the roles of living organisms in the carbon cycle.

plants/produce carbon dioxide, sugars/carbon compounds

What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following head injury? SATA -providing adequate fluids within easy reach -reporting an increasing urine specific gravity -administering prescribed erythromycin -assessing for and reporting changes in neurological status -monitoring for constipation, weightloss, hypotension, and tachycardia

providing adequate fluids within easy reach, assessing for and reporting changes in neuro status, monitoring for constipation, weightloss, hypotension, tachycardia

Critical care nurses can best enhance the principle of autonomy by:

providing the patient with all the information and facts

A client is diagnosed with a brain attack (CVA). The baseline vitals signs are a pulse rate of 78 bpm and a blood pressure of 120/80 mm Hg. The nurse continues to monitor the vitals and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?

pulse 50 bpm and BP 140/60

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. which is the priority concern of the nurse when caring for this client?

skin integrity

Before performing the doll's eyes or oculocephalic reflex, the nurse must verify

the absence of cervical injury

a patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Which of the following statements is true about his spinal cord injury?

the patient has central cord syndrome

which of the following statements is true about a patient with a blunt cardiac injury/cardiac contusion?

treatment can require insertion of a temporary pacemaker for conduction control

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?

use a picture or word board

Values clarification can assist the client to clarify his or her own values to facilitate effective decision making. Which of the following nursing activities is incorporated into this intervention?

use appropriate questions to assist the client in reflecting on the situation and what is personally important

The low pressure alarm sounds on the ventilator. the nurse checks the client and then attempts to determine the cause of the alarm, but is unsuccessful. Which initial action should the nurse take?

ventilate the client manually

Which of the following is ethical principles is most when soliciting informed consent from a client?

veracity

Symptoms of late stages of intracranial hypertension include

widening pulse pressure values