NUR 211 exam 4

case study A new medical resident is working in the ED today. Which action by the resident indicates a need for immediate intervention by the nurse? 1. Assessing for the Babinski sign 2. Increasing the IV infusion rate to 200 mL/hr 3. Ordering an electrocardiogram (ECG) 4. Preparing to perform a lumbar puncture

4- Rationale: Lumbar puncture is contraindicated in a client who may have increased ICP because it increases the risk for herniation of the brainstem through the foramen magnum at the base of the skull. Checking for a positive Babinski sign and obtaining an ECG are not priorities for this client but would not place the client at any increased risk. Increasing the IV rate is appropriate based on the client's blood pressure. Focus: Prioritization

Which planned teaching needs for a patient who is to be discharged postoperatively with a prescription for oxycodone with acetaminophen (Percocet) should be included? Refer the patient to a drug treatment center if addiction occurs. Encourage increased fluids and fiber in the diet. Monitor for gastrointestinal bleeding. Teach the patient to self-assess blood pressure.

Answer: 2 Rationale: Opioids such as hydrocodone with acetaminophen (Percocet) slow peristalsis, which can lead to constipation. Increasing fluids and fiber in the diet may help prevent this adverse effect. Options 1, 3, and 4 are incorrect. Drug treatment programs are not needed if the drug is taken as ordered for the time prescribed. The drugs should not cause GI bleeding and for most patients will not cause a significant drop in blood pressure. Cognitive Level: Applying. Nursing Process: Planning. Client Need: Physiological Integrity.

case study Based on Ms. A's history, vital signs, and assessment data, the client is most at risk for which types of shock? Select all that apply. 1. Cardiogenic 2. Hypovolemic 3. Neurogenic 4. Septic 5. Anaphylactic

2,3 Rationale: Ms. A's bradycardia and hypotension suggest that she is experiencing neurogenic shock in response to her head injury. It is also important to remember that with any traumatic injury, hypovolemic shock caused by hemorrhage should be considered. In this case, Ms. A should be assessed for blood loss associated with her leg injury and for internal bleeding caused by blunt trauma to her chest and abdomen. There are no indications in the client's history that she is at risk for cardiac, septic, or anaphylactic shock. Focus: Prioritization

Question 18 of 20 The nurse is planning health teaching for a client who had a transient ischemic attack (TIA) to help prevent a major stroke. What teaching would the nurse include? (Select all that apply.) Select all that apply. "Seek a smoking cessation program, if needed." "Increase physical activity by exercising regularly." "Monitor blood pressure frequently to assess control." "Take your prescribed antiplatelet agent as prescribed." "If diabetic, work to achieve glucose control as needed." "Eat a heart-healthy diet every day if possible."

A, B, C, D, E, F "Seek a smoking cessation program, if needed." "Increase physical activity by exercising regularly." "Monitor blood pressure frequently to assess control." "Take your prescribed antiplatelet agent as prescribed." "If diabetic, work to achieve glucose control as needed." "Eat a heart-healthy diet every day if possible." All of these instructions are important in helping to prevent a major stroke for a client who had a TIA.

Question 3 of 17 The nurse is assessing a client who is drowsy but easily awakened. What level of consciousness (LOC) would the nurse document for this client? Lethargic Stuporous Alert Comatose

A- Lethargic The client is not alert and awake but can easily be awakened, which is referred to as lethargy. Clients who are stuporous can only be aroused with painful stimuli. Comatose clients cannot be aroused.

A 2-year-old patient is receiving vincristine (Oncovin) for Wilms' tumor. Which of the following findings will the nurse monitor to prevent or limit the main adverse effect for this patient? (Select all that apply.) Numbness of the hands or feet Angina or dysrhythmias Constipation Diminished reflexes Dyspnea and pleuritis

Answer: 1, 3, 4 Rationale: The most serious adverse effect of vincristine is nervous system toxicity. Numbness of the feet or hands, constipation related to decreased peristalsis, and diminished reflexes are all signs of neurotoxicity. Options 2 and 5 are incorrect. Cardiac and pulmonary toxicities are not associated with vincristine. Cognitive Level: Analyzing. Nursing Process: Evaluation. Client Need: Physiological Integrity.

A patient who is undergoing cancer chemotherapy asks the nurse why she is taking three different chemotherapy drugs. What is the nurse's best response? "Your cancer was very advanced and therefore requires more medications." "Each drug attacks the cancer cells in a different way, increasing the effectiveness of the therapy." "Several drugs are prescribed to find the right drug for your cancer." "One drug will cancel out the side effects of the other."

Answer: 2 Rationale: Effectiveness of chemotherapy is increased by use of multiple drugs from different classes that attack cancer cells at different points in the cell cycle. Thus, lower doses of each individual medication can be used to reduce side effects. A third benefit of combination chemotherapy is reduced incidence of drug resistance. Options 1, 3, and 4 are incorrect. A combination of drugs is given for most cancers regardless of how advanced the cancer is. The multidrug is not given to find the right drug because many may exert therapeutic effects. The drugs do not "cancel out" each other but work together. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Physiological Integrity.

Question 2 of 17 A client has just returned from having cerebral angiography. Which assessment finding would lead the nurse to act immediately? Severe headache Bleeding Urge to void Increased temperature

B- Bleeding After a cerebral angiography, the nurse would immediately react if the client had any bleeding. If bleeding is present at the puncture site, manual pressure on the site is maintained along with immediate notification of the primary health care provider. Increased temperature or the urge to void is not typical complications of cerebral angiography. Severe headache is a typical complication of a lumbar puncture, but not of cerebral angiography.

Question 6 of 17 The nurse is caring for a client with impaired vision. The nurse knows the cranial nerve that controls visual acuity is which of the following? Cranial nerve V (trigeminal) Cranial nerve II (optic) Cranial nerve III (oculomotor) Cranial nerve VII (facial)

B- Cranial nerve II (optic) Cranial nerve II (optic) is responsible for vision and cranial nerve III (oculomotor) is responsible for eye movement. Cranial nerve V (trigeminal) allows an individual to feel a light breeze on the face. This nerve is responsible for sensation from the skin of the face and scalp and the mucous membranes of the mouth and nose. Cranial nerve VII (facial) is responsible for pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two-thirds of the tongue.

Question 16 of 20 A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A-V-P-U F-A-S-T K-I-N-D P-Q-R-S-T

B- F-A-S-T The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.

Question 15 of 20 The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone Mannitol Phenytoin Hydrochlorothiazide

B- Mannitol In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema. Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.

Question 5 of 17 Which client diagnosed with neurologic injury is typically at highest risk for depression? Older man with a mild stroke Young man with a spinal cord injury Older woman with a seizure Young woman with a minor closed head injury

B- Young man with a spinal cord injury A young man with a spinal cord injury is at highest risk for depression. Although each individual responds differently, young adults who experience a spinal cord injury and loss of independent movement are more likely to experience depression. Keeping in mind people's differences in personal experiences, the client with a mild stroke without long-term deficits, the client who had a seizure or the young woman who sustained a minor head injury are generally at a lower risk of depression.

Question 12 of 20 The nurse is planning desired outcomes for rehabilitation of a client with traumatic brain injury (TBI). What is the most important outcome for this client? Preventing skin breakdown Preventing further injury Achieving the highest level of functioning Increasing cerebral perfusion

C- Achieving the highest level of functioning The most important nurse's desired or expected outcome for the client having rehabilitation after TBI is to help him or her achieve the highest level of functioning possible. Prevention of injury from falls or skin breakdown, infection, or further impairment of cerebral perfusion is part of ongoing care for this client.

Question 13 of 20 The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign or symptom would the nurse be most concerned about? Head laceration Headache Asymmetric pupils Amnesia

C- Asymmetric pupils The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately. Amnesia, a headache, and a head laceration can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.

Question 14 of 20 A client has had a traumatic brain injury and is mechanically ventilated. Which technique would the nurse use to prevent increasing intracranial pressure (ICP)? Place the client in the Trendelenburg position. Suction the client frequently and as needed. Maintain neutral head position. Assess for Grey Turner sign.

C- Maintain neutral head position. To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP. Grey Turner sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP

A patient has had an acute MI and has received alteplase (Activase) to dissolve the clot. What nursing actions should have been taken prior to administering the medication to the patient?

Prior to administration of alteplase (Activase), laboratory work must be drawn, including CBC, coagulation studies (aPTT, INR), platelet count, kidney and liver studies, lipid profiles, troponin or other cardiac studies, and ABG measurement as ordered. An IV line should be started and any other invasive monitoring or procedures (e.g., indwelling catheter) completed before the infusion of alteplase is started. ECG monitoring should be initiated if it hasn't already been started. A complete health and drug history should be taken, and the nurse should note any potential drug interactions or past history items that would increase the risk of bleeding. The nurse should also explain the procedure to the patient, including all follow-up monitoring and care.

The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? 1. Instructing the client to sit up straight and the client responds with a puzzled expression 2. Moving the client's food tray to the right side of his over-bed table 3. Assisting the client with passive range-of-motion (ROM) exercises 4. Combing the hair on the left side of the client's head when the client always combs his hair on the right side

1 Rationale: Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions. Focus: Delegation, Supervision QSEN: Teamwork & Collaboration Concept: Caregiving

The nurse is in charge of developing a standard plan of care for an Alzheimer disease care facility and is responsible for assigning and supervising resident care given by LPNs/LVNs and delegating and supervising care given by unlicensed assistive personnel (UAP). Which activity is best to assign to the LPN/LVN team leaders? 1. Checking for improvement in resident memory after medication therapy is initiated 2. Using the Mini-Mental State Examination to assess residents every 6 months 3. Assisting residents in using the toilet every 2 hours to decrease risk for urinary incontinence 4. Developing individualized activity plans after consulting with residents and family

1 Rationale: LPN/LVN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents' memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessing for changes in score on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to UAPs working at the long-term care facility. Focus: Assignment QSEN: Teamwork & Collaboration Concept: Collaboration

(Questions 15 through 21) Arterial blood gas values are as follows: Paco2 25 mm Hg (3.33 kPa) Pao2 90 mm Hg (11.97 kPa) HCO3 20 mEq/L (20 mmol/L) O2 saturation 96% (0.96) pH 7.54 Which parameter indicates a need for an immediate change in the ventilator settings? 1. Paco2 2. O2 saturation 3. HCO3 4. Pao2

1 Rationale: Lower-than-normal Paco2 levels cause cerebral vasoconstriction and result in further cerebral hypoxia. The RN should notify the HCP and anticipate a decrease in the ventilator rate. The oxygen percentage being delivered by the ventilator should be evaluated because a lower fraction of inspired oxygen (Fio2) may be adequate. However, the current Pao2 will not have any adverse effect on cerebral perfusion. The decrease in reflects a compensatory mechanism for the client's respiratory alkalosis and will resolve spontaneously when the Pao2 level rises. Focus: Prioritization

The nurse is providing care for a client newly diagnosed with early Alzheimer disease (AD). On assessment, which finding would the nurse expect to discover? 1. Short-term memory impairment 2. Rapid mood swings 3. Physical aggressiveness 4. Increased confusion at night

1 Rationale: One of the first symptoms of AD is short-term memory impairment. Behavioral changes that occur late in the disease progression include rapid mood swings, tendency toward physical and verbal aggressiveness, and increased confusion at night (when light is inadequate) or when the client is excessively fatigued. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Cognition

Case study When the nurse assesses Ms. A at 2:00 pm, her left leg is pale, swollen, and very firm to palpation. The left leg pulses are only faintly audible using a Doppler pulse monitor. Which action is most appropriate at this time? 1. Call the orthopedic surgeon to communicate the assessment. 2. Elevate the left leg on two pillows to decrease the swelling. 3. Continue to monitor the left leg's appearance and pedal pulses. 4. Assess the client for indications of pain, such as restlessness.

1 Rationale: The assessment data suggest the development of compartment syndrome, an emergency that can lead to permanent neuromuscular damage within 4 to 6 hours without rapid treatment. Elevation of the leg will further reduce blood flow to the leg. Continuing to monitor the leg without correcting the compartment syndrome will allow the ischemia to persist. Although restlessness may indicate pain in clients with intact neurologic function, Ms. A's neurologic status is severely compromised, and monitoring for restlessness will not be helpful in assessing for ischemic leg pain. Focus: Prioritization

(Question 11) After being intubated and placed on mechanical ventilation, Ms. A is transported to the radiology department. The CT scans indicate that she has a large epidural hematoma. In addition, chest and left leg radiographs show that she has a left femur fracture and evidence of aspiration pneumonia. When the nurse reassesses Ms. A, she is flaccid and has no response to verbal or painful stimulation. Her pupils are dilated and nonreactive to light. Vital sign values are: Blood pressure 190/40 mm Hg Heart rate 40 beats/min (sinus bradycardia) O2 saturation 92% (0.92) Respiratory rate 14 breaths/min (ventilator controlled) Temperature 96.4° F (35.6° C) (tympanic) Which complication is the nurse most concerned about at present? 1. Brainstem herniation 2. Respiratory acidosis 3. Hemorrhage 4. Hypothermia

1 Rationale: The client's fixed and dilated pupils, widened pulse pressure, and bradycardia are caused by increasing pressure on the brainstem and indicate that she is at risk for brainstem herniation, which would result in brain death. Immediate surgical intervention is needed to prevent this complication. She is at risk for the other complications, but they are not as life threatening. Focus: Prioritization

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? 1. The client no longer recognizes family members. 2. The blood glucose level is 234 mg/dL (13 mmol/L). 3. The client reports a continuing headache. 4. The daily weight has increased 2.2 lb (1 kg).

1 Rationale: The inability to recognize family members is a new neurologic deficit for this client and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the health care provider immediately so that treatment can be initiated. The continuing headache also indicates that the ICP may be elevated but is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment but are not emergencies. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Intracranial Regulation

A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN/LVN whom the nurse is supervising? Select all that apply. 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation 5. Assessing for adverse effects caused by new antiseizure medications 6. Turning the client to his or her side to avoid aspiration

1, 2, 6 Rationale: Any nursing staff member who is involved in caring for the client should observe for the onset and duration of seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Turning the client on his or her side to avoid aspiration is certainly within the scope of practice for an LPN/LVN. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice. Focus: Assignment QSEN: Teamwork & Collaboration, Safety Concept: Intracranial Regulation

The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that apply. 1. When did you first experience the headache symptoms? 2. Who is the Mayor of Cleveland? 3. What is your health care provider's name? 4. What year and month is this? 5. What is your parents' address? 6. What is the name of this health care facility?

1, 3, 4, 6 Rationale: After determining alertness in a client, the next step is to evaluate orientation. When the client's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the client from memorizing the answers. Responses that indicate orientation include the ability to answer questions about person, place, and time by asking for information such as the client's ability to relate the onset of symptoms, the name of his or her health care provider or nurse, the year and month, his or her address, and the name of the referring physician or health care agency. Asking about mayors' names or parents' address may be inappropriate to assess orientation. Focus: Prioritization QSEN: Patient-Centered Care Concept: Cognition

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? Select all that apply. 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client 6. Administering oral medications as ordered

1, 3, 4, 6 Rationale: Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Administering oral drugs is within the scope of practice for an LPN/LVN. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN. Focus: Assignment, Supervision QSEN: Teamwork & Collaboration Concept: Collaboration

All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa is given 3. Reminding the client to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the client with prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function

1, 3, 5 Rationale: UAP education and scope of practice include checking pulse and blood pressure measurements. The nurse would be sure to instruct the UAP to report heart rate and blood pressure findings. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice. Focus: Delegation QSEN: Teamwork & Collaboration Concept: Caregiving

The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply. 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin and nifedipine should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by the client's health care provider.

1,2,3,4,5 Rationale: Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate and should be included in the teaching plan. Focus: Prioritization QSEN: Patient-Centered Care, Evidence-Based Practice, Safety Concept: Patient Education

Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? Select all that apply. 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair

1,2,3,5,6 Rationale: An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. UAPs are also trained to use a client lift to get clients into or out of bed. Assessing for redness and swelling (signs of deep vein thrombosis) requires additional education and skill, appropriate to the professional nurse. Focus: Delegation, Supervision QSEN: Teamwork & Collaboration Concept: Mobility

case study The postcraniotomy care plan for the first postoperative day includes these nursing actions. Which actions can the nurse assign to an experienced LPN/LVN working in the intensive care unit? Select all that apply. 1. Checking the gastric pH every 4 hours 2. Performing a neurologic status examination every 2 hours 3. Assessing breath sounds every 4 hours 4. Turning the client side to side every 2 hours 5. Monitoring intake and output hourly 6. Sending a urine specimen to check specific gravity daily

1,5,6 Rationale: Checking gastric pH, monitoring intake and output, and obtaining urine specimens are included in LPN/LVN education and scope of practice. An experienced LPN/LVN would be expected to report any changes in client status to the supervising RN. Usually repositioning a client would also be included in the LPN/LVN role; however, this client is at risk for increased ICP during positioning and should be monitored by the RN during and after repositioning. Assessments of breath sounds and neurologic status in critically ill clients should be accomplished by an experienced RN. Focus: Assignment

Case study Which of these interventions will be used to meet the goal of maintaining Ms. A's cerebral perfusion pressure (CPP) at 60 mm Hg or more? Select all that apply. 1. Keep the head of the bed elevated 30 degrees. 2. Check pupil reaction to light every hour. 3. Reposition the client at least every 2 hours. 4. Perform endotracheal suctioning as necessary. 5. Check Glasgow Coma Scale score hourly. 6. Administer mannitol 100 mg IV if ICP is above 20 mm Hg. 7. Titrate norepinephrine drip to maintain MAP above 80 mm Hg.

1,6,7 Rationale: Evidence-based guidelines recommend the use of mannitol in clients who have traumatic brain injury with increased ICP to reduce ICP and improve CPP. In hypotensive clients, cerebral perfusion may also be improved by administering vasopressors to raise arterial pressure. Positioning the head of the bed at 30 degrees also reduces cerebral edema by promoting venous drainage from the cerebral circulation. Although neurologic assessments such as checking the Glasgow Coma Scale score and observing pupil reaction to light are necessary, the stimulation caused by these interventions can increase ICP. Suctioning and repositioning also cause transient increases in ICP. It is important to monitor intracranial and arterial pressures during these procedures and modify care to avoid unnecessary increases in ICP. Focus: Prioritization

A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? 1. Position the client sitting up in bed before he or she is fed. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly because there are three more clients to feed. 4. Suction the client's secretions between bites of food.

1- Rationale: Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding. Focus: Delegation, Supervision QSEN: Teamwork & Collaboration, Safety Concept: Nutrition

Patient-focused Case Study Caroline Roberts is a 59-year-old woman who has just flown home from visiting her children and grandchildren on the opposite coast from where she currently lives. She noticed soreness in her left calf muscle, and when she noticed increased pain and swelling in her leg, she made an appointment with her healthcare provider. A diagnosis of DVT is made and the treatment plan is to admit her into the hospital for anticoagulant therapy. 1- Mrs. Roberts asks, "How soon will the heparin dissolve my blood clot?" How would you respond to this question? 2- What patient education should you provide Mrs. Roberts about anticoagulation therapy? 3- What factors predisposed this patient to DVT?

1- Anticoagulants do not dissolve blood clots that have already formed. The human body has a natural mechanism called fibrinolysis. This mechanism will slowly and naturally dissolve any blood clots. However, in the meantime, the heparin will prevent the existing clot from increasing in size. 2- The major emphasis for patients receiving anticoagulation therapy is to prevent injury that may result in internal or external bleeding. A few of the patient education tips that you will want to share with Mrs. Roberts include: Avoid activities that may cause traumatic injury. Use soft cloths and mild soap when bathing. Avoid wearing clothing that is tight or rubs. Avoid blowing or picking the nose. Avoid rectal suppositories or enemas. Watch for bleeding and examine all body fluids for the presence of blood. Avoid drugs that contain aspirin, NSAIDs, and other anticoagulants. 3- Long airplane flights can be problematic, especially for patients who have varicose veins (varicosities). People who travel on flights that last 8 hours or more are 4 times more likely to develop DVT. Air travel may increase the risk of DVT through prolonged sitting and pressure on the calves by the passenger's seat, dehydration as a result of low humidity in the cabin and the consumption of alcohol and caffeine, and decreased air pressure in the plane's cabin.

Lee Sutter, 45 years old, is on a PCA pump to manage postoperative pain related to recent cancer surgery. The PCA is set to deliver a basal rate of morphine of 6 mg/h. As his nurse, you discover Lee to be unresponsive with a respiratory rate of 8 breaths per minute and oxygen saturation of 84%. 1-What should be your first response? 2- What do you anticipate will be needed after that initial response? 3- What follow-up is needed after this time

1- As the nurse, you would call for a rapid response and initially manage the patient's airway, breathing, and circulation (ABCs) by opening the airway and providing oxygen support and then stop the PCA pump. 2- 2- 2- Although the nurse's first reaction may be to go directly to the PCA to stop the medication, it is important initially to manage the patient's airway before stopping the PCA because it is unknown how long the patient has been hypoxic. 3- You would anticipate the need to administer IV naloxone (Evzio, Narcan), which is a narcotic antagonist. After these initial steps have been completed and the patient is stabilized, you would inform the healthcare provider of this adverse effect of the morphine. A change in the basal rate of the PCA may be needed. Mr. Sutter should also be encouraged to continue deep breathing exercises every hour, and to ambulate regularly.

What is the priority nursing concern for a client experiencing a migraine headache? 1. Pain 2. Anxiety 3. Hopelessness 4. Risk for brain injury

1- pain Rationale: The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other problems are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization QSEN: Safety, Teamwork & Collaboration Concept: Pain

Patient-Focused Case Study Ramon de la Cruz is a 27-year-old financial analyst who has recently begun chemotherapy for treatment of Hodgkin's lymphoma. He has tolerated the chemotherapy fairly well but has experienced mild, daily nausea with occasional vomiting, usually controlled by granisetron (Kytril). His main concern is the fatigue he experiences and the impact it has on his work. He also admits that he has been experiencing anorexia and "just doesn't feel like eating much," something which may be contributing to his fatigue. He has lost 2 kg (more than 4 lb) since his last clinic visit 2 weeks ago. 1- As Ramon's nurse, how might you manage his chemotherapy-related nausea and anorexia? 2- What suggestions might assist Ramon in managing his fatigue?

1-As the nurse, you should assess whether Ramon is taking the antinausea drug granisetron (Kytril) regularly or on a prn basis. If he consistently experiences nausea, taking the drug regularly rather than prn may provide better results. Additional antiemetic therapy, perhaps supplementing or switching to another drug group, may be needed. Small sips of ginger ale, without carbonation if desired, may also help relieve nausea. Supplementing his diet with high-protein drinks and eating smaller, more frequent meals may increase oral and caloric intake. Ramon may benefit from a dietary consult, and you could explore this option with him. Improved fluid and caloric intake will keep him in optimal health during the time of his chemotherapy and may help to reduce some of the drug-related fatigue. 2- If Ramon's job allows him to work at home, this might be a viable option during periods of extreme fatigue. Frequent rest breaks while at work, especially if a break room is available in which to lie down, may allow Ramon to continue to work during this time. His employer may be able to offer a shortened workweek, and he could explore medical leave options with the Human Resources department. If there are financial concerns, a social services referral may be advisable.

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? 1. Entering the room without putting on a protective mask and gown 2. Instructing the family that visits are restricted to 10 minutes 3. Giving the client a warm blanket when he says he feels cold 4. Checking the client's pupil response to light every 30 minutes

1. Entering the room without putting on a protective mask and gown Rationale: Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may or may not be appropriate. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia. Focus: Prioritization QSEN: Patient-Centered Care, Teamwork & Collaboration, Safety Concept: Immunity

A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time? 1. Fatigue 2. Inability to perform activities of daily living (ADLs) 3. Decreased mobility 4. Muscular weakness

1. Fatigue Rationale: At this time, based on the client's statement, the priority is inability to perform ADLs most likely related to being tired (fatigue) after physical therapy. The other three nursing concerns are appropriate to a client with MS but are not related to the client's statement. Focus: Prioritization QSEN: Patient-Centered Care Concept: Mobility

Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? 1. Turn the client to one side. 2. Give lorazepam 2 mg IV. 3. Administer oxygen via nonrebreather mask. 4. Assess the client's level of consciousness.

1. Turn the client to one side Rationale: The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side to prevent aspiration. Administering lorazepam should be the next action because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure because generalized tonic-clonic seizures are associated with a loss of consciousness. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Gas Exchange

Case study Ms. A suddenly begins to vomit. Which action should the nurse take first? 1. Use the backboard to log-roll Ms. A to her side. 2. Suction Ms. A's airway with a Yankauer suction device. 3. Hyperoxygenate Ms. A with a bag-valve mask system. 4. Insert a nasogastric tube and connect to low suction.

1. Use the backboard to log-roll Ms. A to her side Rationale: The most important goal for an unconscious client who is vomiting is to prevent aspiration. Turning Ms. A to her side (while maintaining cervical spine stability through the use of the backboard and cervical collar) is the best method to ensure that she does not aspirate. Suctioning would also be utilized but does not clear the airway as well as having the client positioned on her side. Hyperoxygenation may also be required for this client but will not protect the airway while she is vomiting. A nasogastric tube is usually not inserted in clients with possible facial fractures. Insertion of an orogastric tube may be indicated but would not protect from aspiration at the present time. Focus: Prioritization

The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? 1. "I will avoid exercise because the pain gets worse." 2. "I will use heat or ice to help control the pain." 3. "I will not wear high-heeled shoes at home or work." 4. "I will purchase a firm mattress to replace my old one."

1.) "I will avoid exercise because the pain gets worse." Rationale: Exercises are used to strengthen the back, relieve pressure on compressed nerves, and protect the back from reinjury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at all times. Focus: Prioritization QSEN: Patient-Centered Care Concept: Patient Education

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply. 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle 6. Reminding the client to void in a urinal every hour while awake

1.) stroking the clients inner thigh 2.) pulling on the client's pubic hair 4.) pouring warm water over the clients perineum 5.) tapping the bladder to stimulate the detrusor muscle Rationale: All of the strategies except straight catheterization may stimulate voiding in clients with a spinal cord injury (SCI). Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. To use a urinal, the client must have bladder control, which is often absent after SCI. In addition, every hour while awake would be too often and ignore the bladder filling at night. Focus: Prioritization QSEN: Patient-Centered Care Concept: Patient Education

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone 2000 mg IV to treat the infection. 3. Give acetaminophen 650 mg orally to reduce the fever. 4. Give furosemide 40 mg IV to decrease intracranial pressure.

2 Rationale: Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible but are not as important as starting antibiotic therapy. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Infection

Case study About 20 minutes after Ms. A is positioned on her right side, her ICP has increased to 30 mm Hg. Which action should the nurse take next? 1. Administer the as needed (PRN) mannitol 100 mg IV. 2. Assess the alignment of Ms. A's head and neck. 3. Elevate the head of the bed to 45 degrees. 4. Check Ms. A's pupil size and response to light.

2 Rationale: Because the client has just been repositioned, it is likely that the elevated ICP is caused by poor positioning. The head and neck should be maintained in good alignment because neck flexion can cause venous obstruction and an increase in ICP. Administration of mannitol and further elevation of the head of the bed may be needed if repositioning Ms. A's head and neck is ineffective. However, these measures should be used only if her MAP is high enough to maintain a CPP of 60 mm Hg. Checking Ms. A's pupils would not offer any additional information, and the stimulation may increase the ICP. Focus: Prioritization

case study Ms. A's mother, who has been staying at the bedside, asks the nurse why her daughter is receiving omeprazole, stating that her daughter has no history of peptic ulcers. Which answer is best? 1. "Omeprazole will lower the chance that she will aspirate." 2. "Omeprazole decreases the incidence of gastric stress ulcers." 3. "Omeprazole will reduce the risk for gastroesophageal reflux." 4. "Omeprazole prevents gastric irritation caused by the orogastric tube."

2 Rationale: Gastric stress ulcers are a common complication of head injury unless histamine2 (H2) blockers (e.g., famotidine) or proton pump inhibitors (e.g., omeprazole) are administered prophylactically. Administration of omeprazole may decrease the risk of pneumonitis if aspiration occurs, minimize the effects of gastroesophageal reflux, and decrease stomach irritation, but none of the other responses addresses the use of proton pump inhibitors in clients with head injury. Focus: Prioritization

Case study The health care provider (HCP) prescribes these actions. Which action will the nurse take first? 1. Notify family members of Ms. A's admission. 2. Obtain computed tomography (CT) scan of head. 3. Clean the occipital laceration and apply a dressing. 4. Infuse famotidine 20 mg IV every 12 hours.

2 Rationale: National advanced trauma life support guidelines indicate that a CT scan should be done as soon as possible after a closed head injury to determine the extent and types of injury and guide interventions, such as surgery. The other actions are also appropriate for the client but do not need implementation as rapidly. Focus: Prioritization

For which client with severe migraine headaches would the nurse question an order for sumatriptan? 1. A 58-year-old client with gastrointestinal reflux disease 2. A 48-year-old client with hypertension 3. A 65-year-old client with mild emphysema 4. A 72-year-old client with hyperthyroidism

2 Rationale: Sumatriptan is a triptan preparation developed to treat migraine headaches. Most are contraindicated in clients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, and peripheral vascular disease and in those with Prinzmetal angina because of the potential for coronary vasospasm. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Perfusion

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? 1. Assessing the client's respiratory status every 4 hours 2. Checking and recording the client's vital signs every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

2 Rationale: The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses. Focus: Delegation, Supervision QSEN: Patient-Centered Care, Teamwork & Collaboration Concept: Collaboration

The RN notes that a client with myasthenia gravis has an elevated temperature (102.2°F [39°C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's best action at this time? 1. Administer an acetaminophen suppository. 2. Notify the health care provider immediately. 3. Recheck vital signs in 1 hour. 4. Reschedule the client's physical therapy

2 Rationale: The changes that the RN notes are characteristic of myasthenic crisis, which often follows some type of infection. The client is at risk for inadequate respiratory function. In addition to notifying the health care provider or Rapid Response Team, the nurse should carefully monitor the client's respiratory status. The client may need intubation and mechanical ventilation. Focus: Prioritization QSEN: Teamwork & Collaboration, Safety Concept: Clinical Judgment

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first? 1. Administer the ordered acetaminophen. 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the health care provider about the change in status.

2 Rationale: The client's signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the health care provider may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization QSEN: Evidence-Based Practice, Safety Concept: Clinical Judgment

Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? 1. A 34-year-old client with newly diagnosed multiple sclerosis (MS) 2. A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS) 3. A 56-year-old client with Guillain-Barré syndrome (GBS) in respiratory distress 4. A 25-year-old client admitted with a C4-level spinal cord injury (SCI)

2 Rationale: The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care. Focus: Assignment QSEN: Teamwork & Collaboration, Safety Concept: Clinical Judgment

A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3 (2.3 x 109/L). 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

2 Rationale: Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment or client teaching but will not require a change in medical treatment for the seizures. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Clinical Judgment

A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement first? 1. Place the client on the hospital alcohol withdrawal protocol. 2. Transport the client to the radiology department for a computed tomography (CT) scan. 3. Make a referral to the social services department. 4. Give the client phenytoin 100 mg PO.

2 Study Mode: Chapter 9Question 36 of 40ID: 334 Home Help Bookmark < 36 Go >A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement first?Rationale: The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Intracranial Regulation

case study Using the SBAR (situation, background, assessment, recommendations) format, in which order will the nurse communicate this information about the client to the HCP? 1. "I am concerned that Ms. A may develop worsening cerebral hypoxia caused by cerebral vasoconstriction and I would like to decrease the respiratory rate setting on the ventilator." 2. "This is the nurse caring for Ms. A. The client's most recent arterial blood gases (ABGs) indicate that her Paco2 is too low, possibly worsening her cerebral perfusion." 3. "Her current ventilator respiratory rate is set at 20, and ABGs show the Paco2 is 25 mm Hg (3.33 kPa), with a pH of 7.54. O2 saturation is 96% (0.96) with Pao2 of 90 mm Hg (11.97 kPa)." 4. "Ms. A is a 20-year-old woman who had evacuation of an epidural hematoma and has been nonresponsive and ventilator dependent since surgery."

2,4,3,1 Rationale: Using the SBAR format, the nurse first describes the primary concern (situation) and then provides background information about the client. Next, the nurse discusses pertinent assessment data. Finally, recommendations for needed changes in the treatment plan are communicated. Focus: Prioritization

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? 1. The client's condition is improving. 2. The client's condition is deteriorating. 3. The client will need intubation and mechanical ventilation. 4. The client's medication regime will need adjustments.

2- Rationale: The GCS is used in many acute care settings to establish baseline data in these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function. A decrease of 2 or more points in the Glasgow Coma Scale score total is clinically significant and should be communicated to the health care provider immediately. Focus: Prioritization QSEN: Patient-Centered Care, Evidence-Based Practice Concept: Intracranial Regulation

Case study As the shift ends, the nurse is preparing Ms. A for transfer to surgery for an emergency fasciotomy. What is the best option for obtaining informed consent for the fasciotomy? 1. Informed consent is not needed for emergency surgery. 2. Permission for surgery can be given by Ms. A's mother. 3. Consent for surgery is not required for unconscious clients. 4. Authorization can be given by the nursing supervisor.

2- Rationale: When a client is unable to provide informed consent for a procedure, a close family member (who is likely to be most knowledgeable about the client's wishes) is able to give permission. Emergency procedures can take place without written consent for an unconscious or incompetent client when no family or legal representative is available to give permission. The nursing supervisor does not have the authority to consent to surgery for an unconscious client. Focus: Prioritization

Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? 1. A 28-year-old newly admitted client with a spinal cord injury 2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness 3. An 85-year-old client with dementia who is to be transferred to long-term care today 4. A 54-year-old client with Parkinson disease who needs assistance with bathing

2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? 1. A 28-year-old newly admitted client with a spinal cord injury 2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness 3. An 85-year-old client with dementia who is to be transferred to long-term care today 4. A 54-year-old client with Parkinson disease who needs assistance with bathing

A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse tells the nurse that he does not sleep well because he needs to be sure the client does not wander during the night. He insists on checking each of the medications the nurse gives the client to be sure they are "the same pills she takes at home." Based on this information, which nursing problem is most appropriate for this client? 1. Acute client confusion 2. Care provider role stress 3. Increased risk for falls 4. Noncompliance with therapeutic plan

2. Care provider role stress Rationale: The husband's statement about lack of sleep and concern about whether his wife is receiving the correct medications are behaviors that support the problem of care provider role stress. The husband's statements about how he monitors the client and his concern with medication administration do not indicate difficulty complying with the therapeutic plan. The client may be confused, but the nurse would need to gather more data, and this is not the main focus of the husband's concerns. Falls are not an immediate concern at this time. Focus: Prioritization QSEN: Patient-Centered Care Concept: Caregiving

The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

2. Setting up oxygen and suction equipment Rationale: The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins. Focus: Assignment, Supervision QSEN: Teamwork & Collaboration, Safety Concept: Collaboration

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? 1. "Your wife was not admitted within the time frame that alteplase is usually given." 2. "This drug is used primarily for clients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase."

3 Rationale: Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug, such as alteplase, dissolves the clot and can cause more bleeding in the brain. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis. Focus: Prioritization QSEN: Evidence-Based Practice, Safety Concept: Patient Education

case study The LPN/LVN reports that Ms. A's output for the past hour was 1200 mL and that her urine is very pale yellow. Which action is best for the nurse to take at this time? 1. Instruct the LPN/LVN to continue to monitor the urine output hourly. 2. Send a urine specimen to the laboratory to check specific gravity. 3. Notify the neurosurgeon and anticipate an increase in the IV rate. 4. Assess the client's neurologic status for signs of increased irritability.

3 Rationale: Ms. A's high urine output suggests that she has developed diabetes insipidus, a common complication of intracranial surgery. Because diabetes insipidus can rapidly lead to dehydration in a client who is unable to take in oral fluids, the priority action needed is to increase the IV rate. Continuing to monitor the output and checking the specific gravity would also be needed but would not correct the risk for hypovolemia and hypotension. Because Ms. A's neurologic status is so poor, it is unlikely that changes in her neurologic status would be helpful in determining the effects of fluid and electrolyte imbalance. Focus: Prioritization

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? 1. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose 2. A 42-year-old client admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm 3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due 4. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy

3 Rationale: Of the clients listed, the client with bacterial meningitis is in the most stable condition and likely the least complex. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses. Focus: Assignment QSEN: Teamwork & Collaboration Concept: Intracranial Regulation

The nurse is preparing a nursing care plan for a client with a spinal cord injury (SCI) for whom problems of decreased mobility and inability to perform activities of daily living (ADLs) have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes priority? 1. Risk for injury 2. Decreased nutrition 3. Difficulty with coping 4. Impairment of body image

3 Rationale: The client's statement indicates difficulty with coping in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing problems may be appropriate for a client with SCI but are not related to the client's statement. Focus: Prioritization QSEN: Patient-Centered Care Concept: Sensory Perception

Case study Which staff member will be best to assign to take primary responsibility for Ms. A's ongoing care? 1. RN from a temporary agency with extensive previous emergency experience who has been working in this ED for 3 days 2. LPN/LVN with 10 years of experience in the ED who is in the last semester of an RN program 3. RN who has worked in the ED for the past 5 years after transferring from the mother and baby unit 4. RN who has 12 years of intensive care unit experience and has floated to the ED today

3 Rationale: The initial care of clients with traumatic injuries requires the expertise of an RN with extensive ED experience. Neither the agency RN nor the float RN will be familiar with the location of equipment and with the organization of care in the ED. Although the LPN has experience, the LPN/LVN scope of practice does not include the complex assessments and interventions that will be needed in caring for this client. (The LPN could be assigned to assist the RN caring for Ms. A.) Focus: Assignment

A client with Guillain-Barré syndrome (GBS) is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Observe the access site for ecchymosis or bleeding. 2. Instruct the client that there will be three or four treatments. 3. Weigh the client before and after the procedure. 4. Assess the access site for bruit and thrill every 2 to 4 hours.

3 Rationale: The scope of practice for an experienced UAP would include weighing clients. Observing, assessing, and providing instructions all require additional educational preparation and are appropriate to the scope of practice for a professional nurse. Focus: Delegation QSEN: Patient-Centered Care, Teamwork & Collaboration Concept: Caregiving

Case study What is the best approach by the nurse when communicating concerns about the medical resident's decision making? 1. Call the medical resident's supervisor about the concerns. 2. Ask the nursing supervisor to discuss appropriate care with the medical resident. 3. Tell the medical resident that lumbar puncture may cause brainstem herniation. 4. Explain that lumbar puncture is not within the medical resident's scope of practice.

3 Rationale: The Core Competencies for Interprofessional Collaborative Practice indicate that professionals should clearly express knowledge and opinions about client care in order to ensure common understanding of information, treatment, and care decisions. In this situation, the nurse needs to rapidly and clearly communicate with the resident to prevent injury to the client. Calling the resident's supervisor or asking the nursing supervisor to intervene may also be appropriate, but a more direct approach is best in the current situation. The resident will be familiar with medical scope of practice. Focus: Prioritization

Case study Which is the best way to clearly document Ms. A's level of consciousness? 1.Client is comatose. 2.Client is unresponsive. 3.Client's Glasgow Coma Scale score is 4. 4.Client has a decreased level of consciousness.

3- Rationale: The Glasgow Coma Scale offers a standardized and objective way to assess and document neurologic status. Although the other responses also accurately describe the client's level of consciousness, they do not provide objective data that can be readily used to determine changes in the client's neurologic status. Focus: Prioritization

case study The nurse notes that Ms. A has abnormal movement when pressure is applied to her nail beds, as shown in the illustration. What is the best way to document this finding? 1. Extensor rigidity 2. Decorticate posturing 3. Decerebrate posturing 4. Traumatic brain injury

3- Rationale: Decerbrate posturing includes stiff extension of the arms and legs, plantar flexion of the feet, and arm pronation and usually indicates brainstem dysfunction. Documenting extensor rigidity alone would be an incomplete description of the client's assessment. Decorticate posturing involves flexion and internal rotation of the arms. The client clearly does have a traumatic brain injury, but a clear description of the baseline assessment by the nurse is needed. Focus: Prioritization

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection

3. Checking the client's vital signs Rationale: Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury. Focus: Delegation, Supervision QSEN: Teamwork & Collaboration, Safety Concept: Collaboration

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action? 1. Perform a complete neurologic assessment. 2. Assess the cranial nerve functions. 3. Contact the Rapid Response Team. 4. Reassess the client in 30 minutes

3. Contact the Rapid Response Team. Rationale: A change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or health care provider immediately. The nurse should also perform a focused assessment to determine if there are any other changes. Focus: Prioritization QSEN: Patient-Centered Care, Safety Concept: Cognition

A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene? 1. Helping the client ambulate to the bathroom and back to bed 2. Reminding the client not to look at his feet when he is walking 3. Performing the client's complete bathing and oral care 4. Setting up the client's tray and encouraging the client to feed himself

3. Performing the client's complete bathing and oral care Rationale: Although all of these actions fall within the scope of practice for a UAP, the UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence. Focus: Delegation, Supervision QSEN: Patient-Centered Care, Teamwork & Collaboration Concept: Caregiving

(Questions 12 through 14) Ms. A is transported to the operating room, where the epidural hematoma is evacuated and an open reduction and internal fixation of her left leg fracture is completed. After surgery, Ms. A is transferred to the intensive care unit. She is attached to a cardiac monitor and has an arterial line in place. She is making no spontaneous respiratory effort but is being mechanically ventilated. Ms. A's indwelling urinary catheter is draining large amounts of clear, pale yellow urine. An intracranial monitor is in place. Her vital sign values and intracranial pressure (ICP) are as follows: Blood pressure 112/64 mm Hg (mean arterial pressure [MAP], 80 mm Hg) Heart rate 50 to 56 beats/min (sinus bradycardia) ICP 22 mm Hg (reference range, 5-15 mm Hg) O2 saturation 93% (0.93) Respiratory rate 20 breaths/min (ventilator controlled) Temperature 97.4° F (36.3° C) (tympanic) Which of the assessment data listed above requires the most immediate nursing action? 1. Cardiac rhythm 2. Blood pressure 3. O2 saturation 4. ICP

4 Rationale: Normal ICP is 0 to 15 mm Hg, and CPP should be at least 60 mm Hg or higher. CPP is calculated using the formula MAP − ICP = CPP. Ms. A's CPP is 58 mm Hg (80 − 22 = 58); interventions should be implemented immediately to decrease her ICP and improve CPP. The other data indicate a need for ongoing monitoring but do not require immediate intervention. Focus: Prioritization

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

4 Rationale: The first priority for the client with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority. Focus: Prioritization QSEN: Safety Concept: Gas Exchange

An LPN/LVN, under the RN's supervision, is assigned to provide nursing care for a client with Guillain-Barré syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? 1. Reports of numbness and tingling 2. Facial weakness and difficulty speaking 3. Rapid heart rate of 102 beats/min 4. Shallow respirations and decreased breath sounds

4 Rationale: The priority intervention for a client with GBS is maintaining adequate respiratory function. Clients with GBS are at risk for respiratory failure, which requires urgent intervention. The other findings are important and should be reported to the nurse, but they are not life threatening. Focus: Prioritization, Assignment, Supervision QSEN: Teamwork & Collaboration, Safety Concept: Gas Exchange

After the nurse receives the change-of-shift report at 7:00 am, which client must the nurse assess first? 1. A 23-year-old client with a migraine headache who reports severe nausea associated with retching 2. A 45-year-old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. A 59-year-old client with Parkinson disease who will need a swallowing assessment before breakfast 4. A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain

4 Rationale: Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The health care provider should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client. Focus: Prioritization QSEN: Teamwork & Collaboration, Safety Concept: Clinical Judgment

Question 10) The results of laboratory tests that were performed when Ms. A arrived in the ED are faxed to the RN. Complete blood count results are as follows: Hematocrit 42% (0.42) Hemoglobin level 12.6 g/dL (126 g/L) Platelet count 00,000/mm3 (200 × 109/L) White blood cell count 7500/mm3 (7.5 × 109/L) The metabolic profile shows the following: Blood urea nitrogen level 13 mg/dL (4.64 mmol/L) Chloride level 102 mEq/L (102 mmol/L) Creatinine level 0.7 mg/dL (61.88 μmol/L) Glucose level 144 mg/dL (7.99 mmol/L) Magnesium level 1.7 mEq/L (0.85 mmol/L) Potassium level 4.1 mEq/L (4.1 mmol/L) Sodium level 133 mEq/L (133 mmol/L) Arterial blood gas results are as follows: Arterial partial pressure of carbon dioxide (Paco2) 56 mm Hg (7.45 kPa) Arterial partial pressure of oxygen (Pao2) 65 mm Hg (8.64 kPa) Bicarbonate (HCO3) 22 mEq/L (22 mmol/L) O2 saturation 88% (0.88) pH 7.3 Based on the laboratory values, which collaborative intervention will the nurse anticipate next? 1. Type and cross-match for 3 units of packed red blood cells. 2. Administer magnesium sulfate 1 g IV over the next 3 hours. 3. Give insulin aspart dose based on the standard sliding scale. 4. Obtain an endotracheal intubation tray and assist with intubation.

4- Rationale: Ms. A's ABG results indicate uncompensated respiratory acidosis and hypoxemia. Because her respiratory drive is suppressed, she will need rapid intubation and ventilation using a mechanical positive-pressure ventilator. She may need surgery, in which case it would be appropriate to have blood available in the blood bank. Although ongoing monitoring of the magnesium level is indicated, the magnesium level is in the low-normal range, so administration of magnesium is not a priority at this time. Insulin would not typically be administered for a small glucose elevation such as this in a nonfasting client. Focus: Prioritization

Ms. A, a 20-year-old college student who had been drinking at a fraternity party before she fell from a second-floor balcony, has just arrived in the emergency department (ED). A fellow college student who accompanies Ms. A tells the triage nurse, "She was completely knocked out right after the fall. But then she woke up a little, so we thought she was okay—until she stopped moving again." When the nurse assesses Ms. A, there is no response to commands or to having her name called. Her eyes are shut, and she does not open them even when the nurse applies nail bed pressure. Her pupils are unequal, with the right pupil larger than the left. Ms. A's blood pressure is 70/30 mm Hg, she is in a sinus bradycardia with a rate of 40 beats/min, and her respiratory rate is 6 breaths/min. Her respirations are irregular, and she has 20-second periods of apnea. She has a large occipital laceration, and her left leg is misaligned. The paramedics have a cervical collar and backboard in place. A 16-gauge catheter has been inserted at the left antecubital area, and lactated Ringer's solution is infusing at 150 mL/hr. Which additional assessment information is most important to obtain at this time? 1. Temperature 2. Breath sounds 3. Pedal pulses 4.Oxygen saturation

4- Rationale: National guidelines for the emergency management of traumatic brain injury indicate that the assessment of airway and breathing is the priority action for this client. Ms. A's slow and irregular respiratory rate is a risk factor for hypoxemia, which would decrease oxygen delivery to the brain as well as other vital organs and tissues. The other assessment information should also be obtained quickly because Ms. A is at risk for hypothermia, blood loss associated with a possible left leg fracture, and aspiration. Focus: Prioritization QSEN: Concept:

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? 1. "You should avoid consumption of all forms of alcohol." 2. "Wear your medical alert bracelet at all times." 3. "Protect your loved one's airway during a seizure." 4. "It's OK to take over-the-counter medications."

4. "It's OK to take over-the-counter medications." Rationale: A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families. Focus: Delegation, Supervision QSEN: Teamwork & Collaboration, Safety Concept: Patient Education

Question 16 of 17 The nurse is preparing a client for cerebral angiography. Which nursing actions are appropriate as part of care for the client? (Select all that apply.) Select all that apply. Hold any drug that can interfere with kidney function. Communicate any reaction to iodinated contrast to the primary health care provider. Check for a history of acute or chronic kidney disease. Provide adequate hydration before and after the diagnostic test. Ask about the client's history of any and all allergies.

A, B, C, D, E Hold any drug that can interfere with kidney function, Communicate any reaction to iodinated contrast to the primary health care provider, Check for a history of acute or chronic kidney disease, Provide adequate hydration before and after the diagnostic test, Ask about the client's history of any and all allergies The care for the client involves all of these important nursing actions. The client needs adequate hydration to prevent kidney damage from the contrast medium. The nurse ensures that any client allergies are reported to the primary health care provider.

Question 19 of 20 The nurse is planning discharge teaching for a client after having a carotid angioplasty with stenting. As part of health teaching, what symptoms will the nurse teach the client and family to report to the primary health care provider? (Select all that apply.) Select all that apply. Dysphagia Severe neck pain Neck swelling Mild headache Hoarseness

A, B, C, E Dysphagia Severe neck pain Neck swelling Hoarseness The client or family should notify the primary health care provider about complications of the carotid artery surgery, which include all of these choices except they would want to report a severe headache, not a mild one.

Question 15 of 17 The nurse is performing a neurologic assessment for a client and suspects damage to the client's brainstem. Which assessment findings are consistent with brainstem involvement? (Select all that apply.) Select all that apply. Pupil constriction Dysrhythmias Aphasia Irregular respiratory pattern Dysphagia

A, B, D, E Pupil constriction, dysrhythmias, irregular respiratory pattern, dysphagia The brainstem is comprised of the medulla, pons, and midbrain. The nuclei of the cranial nerves that control vital signs (CN X) and swallowing (CN IX-XII) are located in the pons and medulla. CN X (vagus nerve) also controls cardiac and breathing functions. The nuclei of the oculomotor nerve (CN III) causes pupil reaction. When the nerve is damaged, the pupils constrict. Aphasia occurs when the speech and/or language centers in the cerebrum are affected.

Question 17 of 17 The nurse is assessing a client for cerebellar function. Which assessments will the nurse perform? Select all that apply. Gait pattern Muscle strength Coordination Sensation Speech and language

A, C Gait pattern, coordination The cerebellum controls gait, equilibrium, and coordination ability. Muscle strength and speech are functions of the motor strip and Broca area of the frontal lobe of the brain. The sensory strip is located in the parietal lobe.

Question 8 of 17 A diabetic client is scheduled to have a computed tomography-positron emission tomography scan to rule out a brain tumor. What health teaching would the nurse include? "Take your antidiabetic medications as usual before the test." "This test will only take about 20 to 30 minutes to complete." "You'll need to let you doctor know if you have seafood allergies." "You may drink liquids up until an hour before the test."

A- "Take your antidiabetic medications as usual before the test." The test requires the client to be NPO for at least 4 hours before the test, but the client should take any prescribed antidiabetic drugs as usual. The test takes between 2 and 3 hours after the client receives an isotope. This contrast medium is safe for clients who have allergies to seafood

Question 7 of 20 The nurse is teaching assistive personnel (AP) about how to communicate with an older client who has receptive aphasia. Which instruction would the nurse include? "Use simple short sentences and one-step commands." "Work with the speech-language pathologist for suggestions." "Write sentences or words on a white board for the client." "Speak loudly to ensure that the client can hear."

A- "Use simple short sentences and one-step commands." Receptive aphasia is an inability to understand words or sentences, whether it is verbal or written. Therefore, using short simple, one-step sentences and commands is the best instruction to provide AP. Unless the client has a heading deficit, there is no need to talk loudly.

Question 3 of 20 The nurse is caring for a client diagnosed with a vertebrobasilar artery stroke. What assessment finding would the nurse expect for this client? Ataxia Amnesia Unilateral neglect Aphasia

A- Ataxia Aphasia, amnesia, and unilateral neglect are common assessment findings associated with cerebral strokes. Clients who have vertebrobasilar artery strokes have dysfunctions of the cerebellum, such as ataxia, and possibly the brainstem. Clients with this type of stroke typically have weakness in all four extremities rather than one-sided weakness.

Question 12 of 17 The nurse is caring for a client who is scheduled to have a transcranial Doppler (TCD). What does this diagnostic test evaluate? Cerebral vasospasm Intracranial pressure Cerebrospinal fluid Evoked potentials

A- Cerebral vasospasm A transcranial Doppler (TCD) is used to evaluate cerebral vasospasm or narrowing of arteries. It is noninvasive. Cerebrospinal fluid is obtained and measured during a lumbar puncture (LP). Evoked potentials measure the electrical signals in the brain during an EEG. Intracranial pressure is a measurement of blood, brain tissue, and cerebral spinal fluid and is not measured by TCD.

Question 7 of 17 The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? Decreased coordination Increased touch sensation Nightly confusion Increased sleeping during the night

A- Decreased coordination When performing a neurologic assessment on an elderly client, the nurse expects to find decreased coordination. Older adults experience decreased coordination as a result of the aging process. Older adults frequently go to bed earlier and arise earlier than younger adults. Sensation to touch is decreased, not increased. Nightly confusion, sometimes referred to as "sundowning," is not an expected change with all older adults.

Question 11 of 20 The nurse is monitoring a client admitted with a closed traumatic brain injury for indications of increasing intracranial pressure. Which assessment finding would the nurse report to the primary health care provider immediately? Decreased level of consciousness (LOC) Blood pressure of 140/88 Temperature of 100° F (37.8° C) Apical pulse of 90 and regular

A- Decreased level of consciousness (LOC) The first and most important assessment finding associated with increased intracranial pressure that should be reported immediately to the primary health care provider is a decrease in LOC. The vital signs in the choices are near normal and not of great concern.

Question 9 of 17 The nurse is caring for a client who had a lumbar puncture. What priority action would the nurse perform to ensure client safety? Monitor for increased intracranial pressure, such as decreased level of consciousness (LOC). Observe the needle insertion site for cerebrospinal fluid (CSF) leakage or infection. Give an analgesic for client report of a headache if it is moderate or severe. Take vital signs every hour after the procedure until the client is stable.

A- Monitor for increased intracranial pressure, such as decreased level of consciousness (LOC). After a lumbar puncture, the client has less CSF which can cause an expected mild to moderate headache. However, the client may experience increased intracranial pressure which is manifested by decreasing LOC, severe headache, nausea, and vomiting. The nurse monitors for these potentially life-threatening changes. The nurse also monitors for CSF leakage, takes vital signs as per agency protocol, and provides analgesia as needed. However, these actions are not the priority for the nurse at this time.

Question 13 of 17 The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? Trigeminal (CN V) Trochlear (CN IV) Abducens (CN VI) Facial (CN VII)

A- Trigeminal (CN V) The nurse suspects that the trigeminal cranial nerve is affected when a client complains of difficulty chewing when eating. The trigeminal nerve affects the muscles of mastication. The abducens nerve affects eye movement via lateral rectus muscles. The facial nerve affects pain and temperature from the ear area, deep sensations in the face, and taste in the anterior two-thirds of the tongue. The trochlear nerve affects eye movement via superior oblique muscles.

What patient education should be included for a patient receiving enoxaparin (Lovenox)? (Select all that apply.) 1-Teach the patient or caregiver to give subcutaneous injections at home. 2- Teach the patient or caregiver not to take any over-the-counter drugs without first consulting with the healthcare provider. 3- Teach the patient to observe for unexplained bleeding, such as pink, red, or dark brown urine or bloody gums. 4- Teach the patient to monitor for the development of deep vein thrombosis. 5- Teach the patient about the importance of drinking grapefruit juice daily.

Answer: 1, 2, 3, 4 Rationale: Enoxaparin is an LMWH. Patients and family can be taught to give subcutaneous injections at home. Teaching should include instructions to not take any other medications without first consulting the healthcare provider and recognizing the signs and symptoms of bleeding. Enoxaparin is given to prevent development of DVT. Patients should be taught signs and symptoms of DVT and should contact their healthcare provider immediately if these develop or worsen while on enoxaparin therapy. Option 5 is incorrect. Grapefruit juice is known to alter the metabolism of many drugs in the liver. Even though the enoxaparin is given parenterally, it is metabolized in the liver and may be affected by compounds in the grapefruit juice. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Physiological Integrity.

A patient with a congenital coagulation disorder is given aminocaproic acid (Amicar) to stop bleeding following surgery. The nurse will carefully monitor this patient for development of which adverse effects? (Select all that apply.) 1- Anaphylaxis 2- Hypertension 3-Hemorrhage 4- Headache 5-Hypotension

Answer: 1, 4, 5 Rationale: Adverse effects of aminocaproic acid (Amicar) include headache, anaphylaxis, and hypotension. Options 2 and 3 are incorrect. Aminocaproic acid is given to prevent excessive bleeding and hemorrhage in patients with clotting disorders. It may cause hypotension, not HTN. Cognitive Level: Applying. Nursing Process: Evaluation. Client Need: Physiological Integrity.

The patient receiving heparin therapy asks how the "blood thinner" works. What is the best response by the nurse? "Heparin makes the blood less thick." "Heparin does not thin the blood but prevents clots from forming as easily in the blood vessels." "Heparin decreases the number of platelets so that blood clots more slowly." "Heparin dissolves the clot."

Answer: 2 Rationale: Anticoagulants do not change the viscosity (thickness) of the blood. Instead, anticoagulants modify the mechanisms by which clotting occurs. Options 1, 3, and 4 are incorrect. Heparin does not make the blood less viscous or actually thinner and does not decrease the number of platelets or dissolve existing clots. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Physiological Integrity.

A patient has started clopidogrel (Plavix) after experiencing a transient ischemic attack. What is the desired therapeutic effect of this drug? Anti-inflammatory and antipyretic effects To reduce the risk of a stroke from a blood clot Analgesic as well as clot-dissolving effects To stop clots from becoming emboli

Answer: 2 Rationale: Antiplatelet drugs such as clopidogrel are given to inhibit platelet aggregation and, thus, reduce the risk of thrombus formation. Options 1, 3, and 4 are incorrect. Antiplatelet drugs do not exert anti-inflammatory, antipyretic, or analgesic effects. The anti-platelet and anticoagulant drugs do not prevent emboli formation. Thrombolytics dissolve existing blood clots. Cognitive Level: Analyzing. Nursing Process: Evaluation. Client Need: Physiological Integrity.

The nurse notes that the patient has reached his nadir. What does this finding signify? The patient is receiving the highest dose possible of the chemotherapy. The patient is experiencing bone marrow suppression and his blood counts are at their lowest point. The patient has peaked on his chemotherapy level and should be going home in a few days. The patient is experiencing extreme depression and will be having a psychiatric consult.

Answer: 2 Rationale: The nadir is the point of greatest bone marrow suppression, as measured by the lowest neutrophil count. Options 1, 3, and 4 are incorrect. The nadir does not refer to chemotherapy dose, level, or client symptoms. Cognitive Level: Applying. Nursing Process: Assessment. Client Need: Physiological Integrity

A patient with diabetes reports increasing pain and numbness in his legs. "It feels like pins and needles all the time, especially at night." Which drug would the nurse expect to be prescribed for this patient? 1-Ibuprofen (Motrin) 2- Gabapentin (Neurontin) 3- Naloxone (Narcan) 4- Methadone

Answer: 2 Rationale: The patient is describing neuropathic pain, which is most likely to respond to the adjuvant analgesic gabapentin, an antiseizure drug used for neuropathic pain. Options 1, 3, and 4 are incorrect. Nonopioids, such as ibuprofen, or opioids, such as methadone are less effective at relieving pain that is of neurologic origin. Naloxone is an opioid antagonist and will not relieve the patient's pain. Cognitive Level: Applying; Nursing Process: Planning; Client Need: Physiological Integrity.

What is the most effective treatment method for the nausea and vomiting that accompany many forms of chemotherapy? Administer an oral antiemetic when the patient complains of nausea and vomiting. Administer an antiemetic by intramuscular injection when the patient complains of nausea and vomiting. Administer an antiemetic prior to the antineoplastic medication. Encourage additional fluids prior to administering the antineoplastic medication.

Answer: 3 Rationale: For maximum effect, patients should be given an antiemetic prior to the start of treatment. Options 1, 2, and 4 are incorrect. Waiting to give an antiemetic until after the chemotherapy has started may result in a delay in treatment of the nausea and vomiting. IM injections are usually avoided during chemotherapy because of an increased risk of infection. Fluids are encouraged throughout chemotherapy but will not prevent or treat the nausea and vomiting that may occur. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Physiological Integrity.

A patient admitted with hepatitis B is prescribed hydrocodone with acetaminophen (Vicodin), 2 tablets, for pain. What is the most appropriate action for the nurse to take? Administer the drug as ordered. Administer 1 tablet only. Recheck the order with the healthcare provider. Hold the drug until the healthcare provider arrives.

Answer: 3 Rationale: Hydrocodone with acetaminophen (Vicodin) contains acetaminophen, which can be hepatotoxic. This patient has hepatitis B, a chronic liver infection with inflammation, which may affect the metabolism of the drug. Options 1, 2, and 4 are incorrect. The drug should not be given as ordered and the patient may require pain relief before the healthcare provider arrives. It is not within the scope of practice for a nurse to determine the dosage of medication unless the nurse has received advanced specialty practice certification with prescriptive authority. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Safe and Effective Care Environment.

How are monoclonal antibodies such as bevacizumab (Avastin) different from other antineoplastic drugs? They treat many different types of cancer, both blood and solid tumors. They only need to be administered for a short period of time. They are highly specific to certain cell types and target specific cancers. They have fewer adverse effects than traditional antineoplastic drugs.

Answer: 3 Rationale: Monoclonal antibodies used in cancer therapy are highly targeted to specific cell types. They target specific types of cancer with fewer effects on normal cells. Options 1, 2, and 4 are incorrect. Because they are highly specific, they treat selective types of cancer. The period of administration is drug-specific and different drugs require different administration periods. Monoclonal antibodies may cause adverse effects, similar to other drug groups. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Physiological Integrity.

A patient with deep vein thrombosis is receiving an infusion of heparin and will be started on warfarin (Coumadin) soon. While the patient is receiving heparin, what laboratory test will provide the nurse with information about its therapeutic effects? Antithrombin III International normalized ratio (INR) Activated partial thromboplastin time (aPTT) Platelet count

Answer: 3 Rationale: Therapeutic effects of heparin are monitored by the aPTT. While the patient is receiving heparin, the aPTT should be 1.5 to 2 times the patient's baseline, or 60 to 80 seconds. Options 1, 2, and 4 are incorrect. Plasma antithrombin III is activated by heparin to exert anticoagulant effects but is not used to measure heparin activity. An INR is used to monitor the effectiveness of warfarin (Coumadin). Platelets are not affected by anticoagulant therapy and are not useful in monitoring the therapeutic effects of the drug. Cognitive Level: Analyzing. Nursing Process: Evaluation. Client Need: Physiological Integrity.

A patient is receiving a thrombolytic drug, alteplase (Activase), following an acute myocardial infarction. Which effect is most likely attributed to this drug? Skin rash with urticaria Wheezing with labored respirations Bruising and epistaxis Temperature elevation of 38.2 °C (100.8 °F)

Answer: 3 Rationale: Thrombolytics such as alteplase (Activase) dissolve existing clots rapidly and continue to have effects for 2 to 4 days. All forms of bleeding must be monitored and reported immediately. Options 1, 2, and 4 are incorrect. Skin rash, urticaria, labored respirations with wheezing, or temperature elevation are not directly associated with alteplase, and other causes should be investigated. Cognitive Level: Analyzing. Nursing Process: Evaluation. Client Need: Physiological Integrity

The nurse administers morphine 4 mg IV to a patient for treatment of severe pain. Which assessments require immediate nursing interventions? (Select all that apply.) The patient's blood pressure is 110/70 mmHg. The patient is drowsy. The patient's pain is unrelieved in 15 minutes. The patient's respiratory rate is 10 breaths per minute. The patient becomes unresponsive.

Answer: 3, 4, 5 Rationale: Opioids may cause respiratory depression, particularly with the first dose given. The patient's respiratory rate should remain above 12 breaths per minute. Although the patient may also become drowsy, he or she should not become unresponsive after administration of morphine sulfate. Because of the rapid onset of drugs when given IV, if the patient's pain is unrelieved in 15 minutes, the provider should be notified. Options 1 and 2 are incorrect. Drowsiness is a common adverse effect of opioids, and 110/70 mmHg is within normal range for blood pressure. Cognitive Level: Analyzing. Nursing Process: Implementation. Client Need: Physiological Integrity.

The nurse is caring for several patients who are receiving opioids for pain relief. Which patient is at the highest risk of developing hypotension, respiratory depression, and mental confusion? A 23-year-old female, postoperative ruptured appendix A 16-year-old male, post-motorcycle crash injury with lacerations A 54-year-old female, post-myocardial infarction An 86-year-old male, postoperative femur fracture

Answer: 4 Rationale: Older adult patients are at highest risk for hypotension, respiratory depression, and increased incidence of adverse CNS effects, such as confusion. Options 1, 2, and 3 are incorrect. Most 23-year-old patients can tolerate opioids without adverse effects. Individuals who suffer from traumatic injury may receive narcotic analgesia. However, caution should be taken if the individual has also experienced any type of head injury. Opioids are often used with individuals who suffer MI. No adverse effects such as hypotension or respiratory depression are usually present if the dose is appropriate for the size of the patient. Cognitive Level: Analyzing; Nursing Process: Evaluation; Client Need: Physiological Integrity.

The emergency department nurse is caring for a patient with a migraine. Which drug would the nurse anticipate administering to abort the patient's migraine attack? Morphine Propranolol (Inderal) Ibuprofen (Motrin) Sumatriptan (Imitrex)

Answer: 4 Rationale: Triptans such as sumatriptan (Imitrex) are used to abort a migraine attack. Options 1, 2, and 3 are incorrect. Morphine and other narcotics are not effective in aborting a migraine. Propranolol (Inderal) and ibuprofen (Motrin) may be used as adjunctive therapy in migraine therapy but will not stop a headache from occurring. Cognitive Level: Analyzing. Nursing Process: Planning. Client Need: Physiological Integrity.

Which of the following statements by a patient who is undergoing antineoplastic therapy would be of concern to the nurse? (Select all that apply.) "I have attended a meeting of a cancer support group." "My husband and I are planning a short trip next week." "I am eating six small meals plus two protein shakes a day." "I am taking my 15-month-old granddaughter to the pediatrician next week for her baby shots." "I am going to go shopping at the mall next week."

Answer: 4, 5 Rationale: Patients and family members should avoid receiving live virus vaccinations or exposure to chickenpox. The patient could have an exacerbation or a more pronounced episode of the disease. The patient should not care for the granddaughter if vaccination with live viruses is planned. The patient should also avoid crowds, especially in enclosed spaces when possible, to minimize exposure risk. The nurse should discuss measures to minimize the risk of infections if the patient desires to go shopping. Options 1, 2, and 3 are incorrect. Attending a support group, maintaining normal activities when possible, and eating small, frequent meals with sufficient protein are routine care measures during chemotherapy. Cognitive Level: Analyzing. Nursing Process: Assessment. Client Need: Physiological Integrity.

Question 20 of 20 The nurse is caring for a mechanically ventilated client who has an organ donation card and a severe traumatic brain injury. Which assessment findings indicate that the client will be declared as brain dead? (Select all that apply.) Select all that apply. Hypothermia Absence of brainstem reflexes Apnea not due to drugs or diseases Irreversible loss of consciousness Hypotension

B, C, D Absence of brainstem reflexes Apnea not due to drugs or diseases Irreversible loss of consciousness These three assessment findings meet the American Academy of Neurology guidelines for brain death. However, ancillary imaging tests may be used to validate these findings

Question 17 of 20 The nurse is teaching a group of older adults about stroke prevention. Which risk factors for stroke would the nurse include? (Select all that apply.) Select all that apply. Female gender High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives

B, C, D, E High blood pressure, Previous stroke or transient ischemic attack (TIA), Smoking, Use of oral contraceptives Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA. Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

Question 6 of 20 A client completed an alteplase infusion following a thrombotic stroke. What nursing action is appropriate? Insert an indwelling urinary catheter. Perform frequent neurologic assessments. Notify Radiology to schedule an MRI. Administer an antiplatelet agent.

B- Perform frequent neurologic assessments. After administering an alteplase infusion, the nurse performs a focused neurologic assessment, including vital signs, every 15 to 30 minutes, depending on agency protocol and the client's condition. Antiplatelet therapy is not started for at least 24 hours after infusion. A urinary catheter or other invasive tube can cause bleeding and should be avoided. The client would have a CT angiogram or perfusion scan before antiplatelet therapy is initiated.

Question 9 of 20 A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What would the nurse suspect that the client is most likely experiencing? Transient ischemic attack Thrombotic stroke Embolic stroke Hemorrhagic stroke

B- Thrombotic stroke The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset. Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

Question 14 of 17 The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment findings are considered normal? (Select all that apply.) Select all that apply. Decerebrate posturing Lethargy Glasgow Coma Score (GCS) 15 Minimal response to stimulation Pupil constriction to light

C, E Glasgow Coma Score (GCS) 15 Pupil constriction to light Normal rapid neurologic assessment findings include a GCS (Glasgow Coma Score) of 15 and pupil constriction to light. The GCS range is between 3 and 15. Pupil constriction is a function of cranial nerve III. The pupils would be equal in size and round and regular in shape and would react to light and accommodation (PERRLA). Decerebrate or decorticate posturing is not normal, as well as pinpoint or dilated and nonreactive pupils. Both of findings are a late sign of neurologic deterioration. In addition, minimal response to stimulation and increased lethargy are not normal findings.

Question 4 of 17 A client is scheduled for an electroencephalogram (EEG). Which instruction does the nurse give the client before the test? "You may bring some music to listen to for distraction." "Please do not have anything to eat or drink after midnight." "Do not take any sedatives 12 to 24 hours before the test." "You will need to have someone to drive you home."

C- "Do not take any sedatives 12 to 24 hours before the test." Before an EEG, the client needs to be instructed not to use sedatives or stimulants for 12 to 24 hours prior to the test. A client would not fast prior to an EEG as hypoglycemia may alter results. Testing takes place in a quiet room, so music for distraction is not appropriate. Unless the EEG is for sleep disorder diagnosis, the client will not need to be driven home.

Question 2 of 20 A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What would the nurse do first? Perform a focused neurologic assessment. Position the client in a sitting position. Assess airway, breathing, and circulation. Call the primary health care provider.

C- Assess airway, breathing, and circulation. When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation. Calling the Rapid Response Team (RRT), not the primary health care provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for the RRT to assess and begin treatment. This does not need to be a seated position.

Question 4 of 20 The nurse is caring for a client who has a left middle cerebral artery stroke. During shift assessment, the client begins to cry unexpectedly after laughing. What would the nurse suspect that the client is experiencing? Anxiety Delirium Emotional lability Depression

C- Emotional lability Emotional lability is present when the client's emotions change quickly and are not necessarily reflective of the client's mood or a particular situation. This problem is common in clients who have cerebral artery strokes.

Question 1 of 20 The nurse is caring for a client who has a cerebral artery aneurysm. For what complication is the client at risk? Traumatic brain injury Brain cancer Hemorrhagic stroke Embolic stroke

C- Hemorrhagic stroke Aneurysms cause the arterial wall to be weak and thin which can lead to blood vessel rupture or hemorrhage. Therefore, an aneurysm in the brain can rupture and cause a hemorrhagic stroke.

Question 10 of 20 A client is admitted with a stroke. Which tool does the nurse use to facilitate a focused neurologic assessment of the client? Intracranial pressure monitor Mini-Mental State Examination (MMSE) National Institutes of Health Stroke Scale (NIHSS) Glasgow Coma Score (GCS)

C- National Institutes of Health Stroke Scale (NIHSS) The nurse uses the NIHSS tool to perform a focused neurologic assessment. Primary health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients. The Glasgow Coma Score (GCS) provides a nonspecific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.

Question 1 of 17 The nurse is assessing a military veteran who reports frequent headaches. For which neurologic health problem is the client most at risk? Brain cancer Bell palsy Traumatic brain injury Stroke

C- Traumatic brain injury Military veterans are most at risk for traumatic brain injury (TBI) due to explosions that many experienced during wars. Signs and symptoms of TBI can be mild such as headache or memory loss or more severe.

Question 10 of 17 The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? Client who consistently demonstrates decortication when stimulated. Client whose deep tendon reflexes have become hyperactive. Client who displays plantar flexion when the bottom of the foot is stroked. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13.

D - Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13. After receiving report on a group of clients, the nurse's first priority is to assess the client whose GCS has changed from 15 to 13. A decrease of two or more points in the Glasgow Coma Scale total is clinically significant and indicates a major change in neurologic status. This finding must be reported immediately to the primary health care provider (PHCP). The client with hyperactive reflexes, the client displaying plantar flexion when the bottom of the foot is stroked, and the client with decortication upon stimulation will need to be assessed, but they do not require immediate attention.

Question 8 of 20 A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How would the nurse help the client compensate? Approach the client on the affected side. Place objects in the client's field of vision. Encourage turning the head from side to side. Cover the affected eye, if possible.

D- Cover the affected eye, if possible. The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch may help reduce diplopia. The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.

Question 5 of 20 A client has been admitted with a diagnosis of stroke. The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Quick to anger and frustration Inability to discriminate words Aphasia and cautiousness Impulsiveness and smiling

D- Impulsiveness and smiling Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke. Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.

Question 11 of 17 Which information is most important for the nurse to communicate to the primary health care provider about a client who is scheduled for CT angiography? Allergy to penicillin History of bacterial meningitis The client's dose of metformin (Glucophage) held today Poor skin turgor and dry mucous membranes

D- Poor skin turgor and dry mucous membranes The most important information for the nurse to communicate to the PCP about a client scheduled for a CT angiography is the client with poor skin turgor and dry mucous membranes. This assessment indicates dehydration which places the client at risk for contrast-induced nephropathy. Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported as part of the client hand-off to radiology.

A 64-year-old patient has had a long-standing history of migraines as well as coronary artery disease, type 2 diabetes, and hypertension. On review of the medical history, the nurse notes that this patient has recently started on sumatriptan (Imitrex), prescribed by the patient's neurologist. What intervention and teaching is appropriate for this patient?

Sumatriptan (Imitrex) is not recommended for patients with CAD, diabetes, or HTN because of the drug's vasoconstrictive properties. The nurse should refer the patient to the healthcare provider for review of medications and possible adverse reactions related to sumatriptan.

A nurse is taking chemotherapy IV medication to a patient's room and the IV bag suddenly leaks solution (approximately 50 mL) on the floor. What action should the nurse take?

The nurse should remain with the solution and call for someone to bring the chemo spill kit immediately. While waiting for the spill kit, the nurse may cover the contaminated fluid with paper towels (the nurse must not touch the solution without wearing protective equipment). The nurse should clean up the spill and dispose of the waste per hospital protocols. At no time should the chemotherapy spill be left unattended.

Chemotherapy medications often cause neutropenia in patients with cancer. What would be a priority for the nurse to teach a patient who is receiving chemotherapy at home?

The patient and family should be taught about the potential for infection related to immunosuppression. The nurse should stress infection control measures, self-assessing temperature accurately at home, and knowing when to call the oncology provider. Patients should also be taught that infections that occur during chemotherapy will not have symptoms as pronounced as when the patient was not on the drugs. Low-grade fevers, a feeling of general malaise, and other subtle signs of infection may occur and should be reported to the oncology provider.

A 58-year-old woman with a history of a recent MI is on beta-blocker and anticoagulant therapy. The patient also has a history of arthritis and during a recent flare-up began taking aspirin because it helped control pain in the past. What teaching or recommendation would the nurse have for this patient?

The patient should be taught not to take any medication, including OTC medications, without the approval of the healthcare provider. This patient is taking an anticoagulant, and aspirin increases bleeding time. The patient needs to be taught how to recognize the signs and symptoms of bleeding related to the anticoagulant therapy. The patient should review with the healthcare provider all her medications. Possibly, her anti-inflammatory medication can be changed from aspirin to another drug for treatment of arthritis.

A patient is receiving enoxaparin subcutaneously after being diagnosed with thrombophlebitis. What precautions should be taken when giving this medication?

Whether the nurse gives this drug or is teaching the patient to self-administer the medication, proper placement of the needle in the abdomen is vital. The injection must be given at least 1 to 2 inches away from the umbilicus using the syringe supplied by the manufacturer. The air bubble included in the syringe should not be expelled to ensure full drug injection. The skin is pinched (drawn up) and the needle inserted at a 90-degree angle. Aspiration is not used. After giving the injection, slight pressure is held at the site and the site is not massaged.