Pepu test 6

Which level of the triage system is implemented when the patient requires two or more resources? a) Minor b) Urgent c) Emergent d) Nonurgent

B

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? a) Comminuted b) Simple c) Basilar d) Depressed

C, Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a) Cardiogenic emboli b) Small artery thrombosis c) Large artery thrombosis d) Cerebral aneurysm

D

A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? a) 6.3 mg b) 7.5 mg c) 8.3 mg d) 10 mg

A, A person who weighs 154 lbs weighs 70 kg. To calculate dosage, multiply 70 × 0.9 mg/kg = 63 mg. The nurse gives 10% (6.3 mg) over 1 minute.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a) The day the patient has the stroke b) After the patient has passed the acute phase of the stroke c) The day before the patient is discharged d) After the nurse has received the discharge orders

A, Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effor

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a) Semi-Fowler's b) High-Fowler's c) Prone d) Supine

A, The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family? a) Look for signs of increased intracranial pressure b) Look for a halo sign c) Emphasize complete bed rest d) Have the patient avoid physical exertion

A, The nurse informs the family to monitor the patient closely for signs of IICP if findings are normal and the patient does not require hospitalization. The nurse looks for a halo sign to detect any CSF drainage.

A nurse working as part of a disaster response team is triaging clients. Which of the following clients would the nurse color code as green? Select all that apply. a) Client with a fractured arm b) Client with multiple injuries in profound shock c) Client with a first-degree burn to the forearm d) Client with a sucking chest wound e) Unresponsive client with a penetrating head wound

A,C In triage, green indicates minor injuries for which treatment can be delayed hours to days. A client with a fractured arm or with a first-degree burn would be triaged green. A client with a sucking chest wound would require immediate care and be triaged red. An unresponsive client with a penetrating head wound or with multiple injuries and in profound shock would be triaged black because the injuries are extensive and chances of survival are unlikely, even with definitive care.

Following a disaster, a client's condition is serious, but she is stable enough to survive if treatment is delayed 6 to 8 hours. What category of triage would the nurse place this client? a) Green b) Yellow c) Red d) Black

B, A client in the yellow category is considered "delayed" triage, meaning the condition is serious, but stable enough for the client to survive if treatment is delayed 6 to 8 hours.

Which of the following would be a pulse pressure indicative of shock? a) 120/90 b) 90/70 c) 100/60 d) 130/90

B, A narrowing or decreased pulse pressure is an early indicator of shock, thus 90/70 indicates a narrowing pulse pressur

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? a) Hyperactive bowel sounds b) Decreased peristalsis c) Hematemesis d) Fecal occult blood

B, Decreased peristalsis and hypoactive bowel sounds are manifestations of a paralytic ileus.

Which of the following is a common cancer that metastasizes to the spinal cord? Select all that apply. a) Brain b) Breast c) Colon d) Lung e) Prostate

B,D,E Cancer can spread to the spinal cord. The three most common cancers that metastasize to the spinal cord are breast, prostate, and lung. Cancer can invade the cord, causing vertebral metastases. Colon and brain cancers do not commonly metastasize to the spinal cord.

Which of the following psychotropic drug classifications is often prescribed for neuropathic pain? a) Antipsychotics b) Tricyclic antidepressants c) Anxiolytics d) Mood stabilizers

B,Tricyclic antidepressants are often prescribed for neuropathic pain

Which type of burn injury requires skin grafting? a) Superficial b) Deep partial-thickness c) Full-thickness d) Superficial partial-thickness

C, A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is a) Salt-poor albumin b) Packed red blood cells c) Dextran d) Hetastarch

C, Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

A patient has been diagnosed with a lipoma. The nurse explains to the patient that this tumor is located in the part of the brain known as the: a) Optic chiasm. b) Cerebrum. c) Corpus callosum. d) Brainstem.

C, The corpus callosum is a thick collection of nerve fibers that connect both hemispheres of the brain and is responsible for transmitting information from one side of the brain to another. A lipoma only occurs in this area.

Which of the following is not a manifestation of Cushing's Triad? a) Bradycardia b) Bradypnea c) Hypertension d) Tachycardia

D, Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: a) Entire dermis and subcutaneous tissue. b) Dermis and connective tissue. c) Epidermal layer only. d) Epidermis and a portion of deeper dermis.

D, A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn

Loss of 15% to 30% of blood volume would be classified as which type of shock? a) Class I b) Class III c) Class IV d) Class II

D, Loss of 15% to 30% of blood volume is classified as Class II hemorrhage. A Class I hemorrhage is loss of up to 15% of blood volume. Class III is loss of 30% to 40% of blood volume. Class IV is loss of >40% of blood volume.

From which direction should a nurse approach a client who is blind in the right eye? a) From directly behind the client b) From the right side of the client c) From directly in front of the client d) From the left side of the client

D, The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.

A patient has been diagnosed with a brain tumor, a glioblastoma multiforme. The nurse met with the family after the diagnosis to help them understand that: a) The tumor rarely spreads to other parts of the body. b) Chemotherapy, following surgery, has recently been shown to be a highly effective treatment. c) Radiation is not an option because of the tumor's location near the brainstem. d) Surgery can improve survival time but the results are not guaranteed.

D, The overall prognosis for this type of aggressive brain tumor is poor but surgery can improve survival time.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: a) nuchal rigidity and Kernig's sign. b) motor loss in the legs that exceeds that in the arms. c) pupillary changes. d) raccoon's eyes and Battle sign.

D, basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. a) 60 mm Hg b) 90 mm Hg c) 80 mm Hg d) 70 mm Hg

A, Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients. The formula for calculating MAP is (2 × diastolic + systolic × 3)

A health care provider needs help in identifying the precise location of a brain tumor. To measure brain activity, as well as to determine structure, the nurse expects the health care provider to order which of the following tests? a) MRI b) Computed tomography (CT) c) Positron-emission tomography (PET) d) Computer-assisted stereotactic biopsy

C, A PET scan is most diagnostic for brain activity, as well as for assessment of tumor size. It can also be useful in differentiating a tumor from scar tissue or radiation necrosi

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? a) Reposition the client frequently. b) Assess for pupillary response frequently. c) Take daily weights. d) Assess vital signs frequently.

C, A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

Which of the following is the only known risk factor for brain tumors? a) Cellular telephones b) Use of hair dyes c) Ionizing radiation d) Head trauma

C, Ionizing radiation is the only known risk factor for brain tumors. Head trauma, use of hair dyes, and use of cellular phones are possible causes that have been investigated.

When a patient is in the compensatory stage of shock which of the following symptoms occurs? a) Respiratory acidosis b) Urine output of 45 cc/hour c) Tachycardia d) Bradycardia

C, The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse? a) Sexual history b) Blood pressure and weight c) Frequent neurologic checks d) Motor and sensory responses

C, f the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia. Body weight is measured because obesity, hyperlipidemia, and atherosclerosis are related to cerebrovascular disease, and not in the case of carotid artery surgery. Sexual history and motor and sensory responses are not important assessments to be performed for such clients.

Hyperglycemia for a patient with a TBI may worsen the outcome of recovery. Select a serum glucose level that is considered critical. a) 120 mg/dL b) 80 mg/dL c) 140 mg/dL d) 180 mg/dL

D, A serum glucose level of over 150 mg/dL is considered a critical value.

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) An infusion of crystalloids at an increased rate of flow c) Isotonic enteral nutrition every 6 hours d) A continuous infusion of total parenteral nutrition

D, Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? a) Shaves the hair around the wound b) Administers acetaminophen (Tylenol) for headache c) Administers an oral analgesic for pain d) Irrigates the wound to remove debris

D, Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection

A patient has recently been diagnosed with an acoustic neuroma. The nurse helps the patient understand that: a) Almost 80% of these tumors become malignant over time. b) Surgery is never needed; radiation has proven very effective. c) Compression of the seventh cranial nerve is a side effect. d) Hearing loss usually occurs.

D. An acoustic neuroma is a benign tumor of the eighth cranial nerve. About 50% can be treated with surgery. Hearing loss always occurs. Compression on the fifth cranial nerve can also cause facial paresthesia.

A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture? a) Basilar b) Linear c) Simple d) Comminuted

A , Bruising over the mastoid bone and rhinorrhea is indicative of a basilar skull fracture. A simple (linear) fracture is a break in the continuity of the bone. A comminuted fracture refers to a splintered or multiple fracture line

Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock? a) Modified Trendelenburg b) Semi-Fowler's c) Supine d) Prone

A, A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood.

Which of the following are the immediate complications of spinal cord injury? a) Spinal shock b) Respiratory arrest c) Paraplegia d) Tetraplegia

A, Respiratory arrest and spinal shock are the immediate complications of spinal cord injury. Tetraplegia is paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury

In a client with burns on the legs, which nursing intervention helps prevent contractures? a) Performing shoulder range-of-motion exercises b) Applying knee splints c) Elevating the foot of the bed d) Hyperextending the client's palms

B, Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

Evaluating the level of consciousness using the Glasgow Coma Scale is an essential nursing assessment for a patient who has had an intracerebral hemorrhage. Which of the following scores would indicate the need for immediate intubation? a) 12 b) 8 c) 10 d) 15

B, Scores on the Glasgow Coma Scale range from 3 to 15. A score of 8 or less is cause for immediate intubatio

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? a) Hormone antagonist drugs b) Antimetabolite drugs c) Adrenergic drugs d) Anticholinergic drugs

C, Adrenergic drugs are the main medications used to treat shock

A 57-year-old client has been brought to your ED via squad. He is unresponsive and his wife is presenting his recent history. She reports his symptoms of elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. His labs show an elevated WBC; cultures are forthcoming. Why is time of the essence in treating this client's condition? a) Cardiogenic shock is the deadliest form of shock b) Anaphylactic shock is the deadliest form of shock c) Septic shock is the deadliest form of shock d) Neurogenic shock is the deadliest form of shock

C,Hypovolemic shock is quite common, but septic shock, a form of distributive shock, is the 10th most common cause of death overall.

Which of the following is a clinical manifestation of cardiac tamponade? a) Bradycardia b) Hypertension c) Widening pulse pressure d) Narrowing pulse pressure

D, Signs and symptoms of cardiac tamponade include narrowing pulse pressure, chest pain, distant or muffled heart sounds, jugular vein distention, hypotension, and tachycardia.

When describing the use of smallpox as a biologic agent, which of the following would the nurse include as the primary means of infection? a) Inhalation b) Percutaneous absorption c) Ingestion d) Direct contact

D, Smallpox is extremely contagious and infection occurs by direct contact, contact with clothing or linens, or droplets from person to person only after the fever has decreased and the rash phase has begun. Anthrax occurs via inhalation, skin contact, or gastrointestinal ingestion. Nerve agents can be precutaneously absorbed

A client has undergone surgery for a spinal cord tumor that was located in cervical area. The nurse would be especially alert for which of the following? a) Bowel incontinence b) Skin breakdown c) Hemorrhage d) Respiratory dysfunction

D, When a spinal tumor is located in the cervical area, respiratory compromise may occur from postoperative edema. Hemorrhage would be a concern with any surgery. Bowel incontinence and skin breakdown are possible but not specific to cervical spinal tumors.

Which of the following provides the best outcome for most tumor types? a) Surgery b) Radiation c) Chemotherapy d) Palliation

A, Surgical intervention provides the best outcome for most tumor types. The objective of surgical management is the removal of part of or the entire tumor without increasing the neurologic deficit. Radiation, chemotherapy, and palliation may be used for the patient with a brain tumor, but it does not provide the best outcome for most tumor types

Which of the following colloids is expensive but rapidly expands plasma volume? a) Dextran b) Albumin c) Hypertonic saline d) Lactated Ringer's

B, Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer's and hypertonic saline are crystalloids, not colloids

Which of the following is the initial diagnostic in suspected stroke? a) CT with contrast b) Cerebral angiography c) Noncontrast computed tomography (CT) d) Magnetic resonance imaging (MRI)

C, An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

Inhalation of anthrax mimics which disease process? a) Burns b) Bronchospasm c) Respiratory distress d) Flu

D, Anthrax symptoms mimic those of the flu, and usually treatment is sought only when the second stage of severe respiratory distress occurs. Burns occur with sulfur mustard. Bronchospasm can occur with phosgene or chlorine. Respiratory distress may occur with cyanide.

A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? a) Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. b) Contusions are deep brain injuries. c) Contusions are microscopic brain injuries. d) Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow.

A Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore options B, C, and D are incorrect.

A patient is being treated for septic shock. On assessment, the nurse notes an abnormal finding that is reported to the health care provider. Which of the following is most likely that finding? a) SVO2 of 55% b) MAR reading of 65 mm Hg c) CVP reading of 10 d) Urinary output of 60 mL/hr

A, Normal SVO2 values range from 60% to 80%. Lower values indicate inadequate tissue perfusion and the need for medical intervention.

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? a) 4:00 p.m. b) 5:30 p.m. c) 2:30 p.m. d) 3:00 p.m.

A, Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

Which of the following are clinical manifestations associated with increased intracranial pressure (ICP)? Select all that apply. a) Seizures b) Angina c) Headache d) Papilledema e) Nausea with or without vomiting

A,C,D,E Symptoms of increased intracranial pressure include headache, nausea with or without vomiting, and papilledema. Angina is not associated with increased ICP.

Which of the following is an accurate statement regarding malignant brain tumors? Select all that apply. a) They are slow-growing. b) They are life-threatening. c) They are rapidly growing. d) They can spread into surrounding tissue. e) They rarely cause death.

B, C,D,Malignant tumors are rapidly growing in nature, can spread into surrounding tissue, and are considered life-threatening.

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and their family? a) Rapid heart rate b) Sweating c) Runny nose d) Slight headache

B, Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

Which of the following terms is used to describe edema of the optic nerve? a) Angioneurotic edema b) Papilledema c) Scotoma d) Lymphedema

B, Papilledema is edema of the optic nerve. Scotoma is a defect in vision in a specific area in one or both eyes. Lymphedema is the chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary dissection. Angioneurotic edema is a condition characterized by urticaria and diffuse swelling of the deeper layers of the skin.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a) Bradypnea b) Hoarseness c) Facial burns d) Singed nasal hair e) Yellow sputum

BCD

Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? a) All options are correct b) Hands, major joints c) Face, neck, chest d) Perineal

C

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? a) Altered intellectual ability b) Aphasia c) Left visual field deficit d) Slow, cautious behavior

C, A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.

The nurse reviews the patient's drug regimen for treatment of a brain tumor. She explains to the patient why one of the following drugs would not be prescribed, even though it might have therapeutic benefits. Which drug would not be prescribed for this patient? a) Paclitaxel b) Decadron c) Coumadin d) Dilantin

C, Although deep vein thrombosis and pulmonary embolism occur in about 15% of patients and cause significant morbidity, anticoagulants are not prescribed due to the risk for CNS hemorrhage.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a) Intracranial pressure is increased by a space-occupying bleed. b) A ruptured arteriovenous malformation will cause deficits until it is stopped. c) Thrombolytic therapy has a time window of only 3 hours. d) A ruptured intracranial aneurysm must quickly be repaired.

C, Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes

A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following? a) "My headache and nausea should be lessened somwhat." b) "There will be less cancer left that might be resistant to chemotherapy." c) "The surgeon will be able to remove all of the tumor." d) "Any tissue that was dead will be removed."

C, For clients with malignant gliomas, complete removal of the tumor and cure are not possible but the rationale for resection includes relief of increased intracranial pressure, removal of any necrotic tissue, and reduction in the bulk of the tumor, which theorectically leaves behind fewer cells to become resistant to radiation or chemotherapy.

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient a) complains of headache. b) complains of generalized weakness. c) vomits. d) sleeps for short periods of time.

C, Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in the patient with a concussion is an expected abnormal observation. However, a severe headache should be reported or treated immediately. Weakness of one side of the body should be reported or treated immediately. Difficulty in waking the patient should be reported or treated immediately

The nurse observes for fluid and electrolyte changes during the acute phase based on the knowledge that fluid remobilization usually begins: a) After 10 days, when scar tissue begins to cover the wound and prevent evaporative fluid loss. b) After 5 days, when capillary permeability has returned to normal. c) After 48 to 72 hours later, when fluid is moving from the interstitial to the intravascular compartment. d) Within the first 24 hours, when massive amounts of fluid are being administered intravenously.

C, When fluid shifts back to the intravascular compartment, a number of electrolyte changes can occur. Refer to Table 53-4 in the text

A client comes to the clinic for evaluation because of complaints of dizzinesss and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain? a) Occipital lobe b) Frontal lobe c) Cerebellum d) Motor cortex

C,Findings such as ataxic or staggering gait, dizziness, marked muscle incoordination, and nystagmus suggest a cerebellar tumor. A frontal lobe tumor frequently produces personality, emotional, and behavioral changes. A tumor in the motor cortex produces seizurelike movements localized on one side of the body. Occipital lobe tumors produce visual manifestations.

A 37-year-old mother of three has just been diagnosed with a grade I meningioma. As part of patient education, the nurse tells the patient that: a) The tumor will cause pressure on the eighth cranial nerve. b) The tumor is malignant and aggressive. c) Surgery, which can result in complete removal of the possible tumor, should be done as soon as possible. d) Growth is slow and symptoms are caused by compression rather than tissue invasion.

D, A meningioma is benign, encapsulated, and slow-growing. Sometimes the patient has no symptoms because of the slow-growing nature of the tumo

Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane? a) Subdural hematoma b) Extradural hematoma c) Intracerebral hemorrhage d) Epidural hematoma

A, A subdural hematoma is bleeding between the dura mater and arachnoid membrane. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma: a) Originated within the brain tissue. b) Originated from the coverings of the brain. c) Metastasized from a cancer in another part of the body. d) Developed on the cranial nerves.

A, The most aggressive type of malignant brain tumor is a glioma, which originates within the brain tissue.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? a) The early appearance of the burn injury may change. b) The wound is susceptible to infections. c) The client's condition is likely to deteriorate after 72 hours. d) It helps determine the percentage of the total body surface area (TBSA) that is burned.

A, The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: a) Measure hourly urinary output. b) Replace lost fluids and electrolytes. c) Prevent renal shutdown. d) Monitor cardiac status.

B, After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula

Which of the following is an action of the osmotic diuretic mannitol? Select all that apply. a) Decreases seizure activity b) Reduces blood viscosity c) Enhances cerebral blood flow d) Dehydrates brain tissue e) Reduces cerebral edema

B,C,D,E Osmotic diuretics may be administered to dehydrate the brain tissue and reduce cerebral edema. Osmotic diuretics work by creating a gradient that draws water across intact membranes, thereby reducing the volume of the swollen brain. Secondarily, they reduce blood viscosity and hematocrit and enhance cerebral blood flow.

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? a) Atorvastatin b) Extended release dipyridamole c) Tissue plasminogen activator (tPA) d) Clopidogrel

C

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? a) L4 b) T10 c) S2 d) T6

D, Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role? a) Provision of comprehensive client-specific care b) Client care within the area of expertise c) Directly specified by the physician in charge d) Variable depending on the needs of the situation

D, The role of the nurse during a disaster varies and depends on the needs or situation. Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. During a disaster, nursing care focuses on essential care from a perspective of what is best for all clients.

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? a) Diastolic pressure of 110 mm Hg b) Heart rate of 100 c) Systolic pressure of 180 mm Hg d) Respiration of 22

A, A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range. Refer to Table 47-5 in the text.

A nurse assesses a patient who has been diagnosed with having a pituitary adenoma that is pressing on the third ventricle. The nurse looks for the associated sign/symptom. What is that sign/symptom? a) Increased intracranial pressure b) Unusual sensitivity to heat and cold c) Visual disturbances d) Disruption in sleep patterns

A, All the choices are signs and symptoms that can occur with an adenoma, depending on whether the pressure is exerted on the hypothalamus, the third ventricle, or the optic nerves, chiasm, or tracts. Increased intracranial pressure occurs when the third ventricle is affected.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a) Lioresal (Baclofen) b) Pregabalin (Lyrica) c) Heparin d) Diphenhydramine (Benadryl)

A, Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal)

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? a) Deep partial-thickness b) Superficial c) Full-thickness d) Superficial partial-thickness

B, A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? a) Thoracotomy with chest tube insertion b) Intubation and mechanical ventilation c) Pericardiocentesis d) Administration of oxygen via venture mask

B, Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn? a) Sodium loss b) Hyperglycemia c) Polyuria d) Hypoglycemia

B, When the adrenal cortex is stimulated, it releases glucocorticoids , which cause hyperglycemia. Sodium retention leads to peripheral edema. There is a decreased urine output, initially.

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Furosemide (Lasix) b) Lansoprazole (Prevacid) c) Ranitidine (Zantac) d) Desmopressin (DDAVP) e) Famotidine (Pepcid)

B,C,E Antacids, H2 blockers (Pepcid, Zantac), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. DDVAP is used in the treatment of diabetes insipidus. Lasix is a loop diuretic and does not prevent ulcer formation.

Nursing students are reviewing the various types of brain tumors. The students demonstrate understanding of the material when they identify which of the following as the most common type? a) Meningiomas b) Pituitary adenomas c) Gliomas d) Acoustic neuromas

C , Gliomas are the most common type of intracerebral brain tumor. Menigiomas account for approximately 15% of all primary brain tumors. Pituitary adenomas represent approximately 10% to 15% of all brain tumors. Acoustic neuromas are less common.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? a) Crust around the pin insertion site b) A slight reddening of the skin surrounding the insertion site c) A small amount of yellow drainage at the left pin insertion site d) Pain at the insertion site

C, The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: a) Cardiomyopathies. b) Arrhythmias. c) Valvular damage. d) A myocardial infarction.

D,Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

To prepare the community for the possible threat of anthrax, a nurse must teach that: a) anthrax can infect the integumentary, GI, and respiratory systems. b) physicians use isoniazid (INH), rifampin (Rifadin), and pyrazinamide to treat anthrax. c) immunizations can prevent anthrax. d) blood and body secretions can transmit anthrax.

A, Anthrax can infect the integumentary, GI, and respiratory systems. Immunizations are appropriate only for those at risk of anthrax exposure. Isoniazid, rifampin, and pyrazinamide are used to treat tuberculosis, not anthrax. Penicillin is the most common drug used to threat anthrax

In a client who has been burned, which medication should the nurse expect to use to prevent infection? a) Meperidine (Pethidine) b) Mafenide (Sulfamylon) c) Permethrin (LyClear) d) Diazepam (Valium)

A, The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Permethrin is used to treat scabies infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Head injury b) Diabetes c) Multiple sclerosis d) Myocardial infarction

A,An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? a) Hypophysectomy b) Burr holes c) Insertion of Crutchfield tongs d) Application of Halo traction

B, An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes; see Fig. 66-8 in Chapter 66) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

Cushing's triad is a late sign of increased intracranial pressure (ICP). Which of the following clinical manifestations correlate with Cushing's triad? a) Tachycardia b) Widening pulse pressure c) Hypotension d) Tachypnea

B, Late signs associated with rising ICP related to the vital signs (Cushing's triad) include hypertension with a widening pulse pressure, bradycardia, and respiratory depression.

A halo sign is indicative of which of the following complication of brain injury? a) Seizure b) Ischemia c) Cerebrospinal fluid (CSF) leak d) Cerebral edema

C, A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. A positive halo sign is not indicative of seizure, cerebral ischemia, or cerebral edema.

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: a) Smoking b) Dyslipidemia c) Obesity d) Hypertension

D, Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

Which category of the traditional triage system is reserved for patients who do not have life-threatening illnesses? a) Fast-track b) Urgent c) Emergent d) Nonurgent

D, Nonurgent patients are those who do not have life-threatening illnesses. Emergent patients are the highest priority or may have life-threatening injuries. Urgent patients are those with serious health problems that are not considered immediately life-threatening. Fast-track patients are those who require simple first aid.

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a) Intracerebral b) Cerebral c) Subdural d) Epidural

C, A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? a) Demerol b) Codeine c) Morphine d) Dilaudid

C, If a patient experiences chest pain, IV morphine is administered for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also decreases the patient's anxiety and reduces the respiratory rate, and thus oxygen consumption.

An alarm has reached your ED regarding a serious MVA between a full tour bus and a school bus — the number of casualties expected is quite high. While part of your staff is sent to the accident site, the remaining staff readies your unit for mass traumas. At the accident site, your practice begins. As a nurse, what would you expect as your top priority? a) Organize volunteers b) Set-up communication system c) Get forms ready for completion d) Assess as many victims as possible at the site

D, Assess as many victims as possible at the scene of the disaster to manage time efficiently and to avoid overwhelming valuable resources

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Right-sided stroke b) Transient ischemic attack c) Left-sided stroke d) Cerebral aneurysm

B, A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm

Which of the following diagnostic studies provides visualization of cerebral blood vessels? a) Positron emission tomography (PET) b) Cerebral angiography c) Computer-assisted stereotactic biopsy d) Cytologic studies of cerebrospinal fluid (CSF)

B, Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral trauma. A PET scan measures the brain's activity and is useful in differentiating tumor from scar tissue or radiation necrosis. Cytologic studies of the cerebral spinal fluid (CSF) may be performed to detect malignant cells because central nervous system tumors can shed cells into the CSF. Computer-assisted stereotactic biopsy is being used to diagnose deep-seated brain tumors.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a) Immediate b) Emergent c) Urgent d) Nonacute

B, The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to nonacute, non-life-threatening injury or illness.

In your role as a public health nurse, you offer public education in high school classes on personal responsibility in preventing head injuries as a way of life. While avoiding alcohol and drugs not only complies with existing law for minors, it also is an available intervention to prevent head injuries. Which of the following are measures available to prevent head injuries? a) None of the options are correct b) Using seatbelts c) Holding infants tightly while riding in an automobile d) Lowering neck restraints on seatbacks

B, To reduce the potential for both minor and life-threatening head injuries, the nurse stresses the importance of using seatbelts for all passengers in automobiles.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: a) Decrease heart rate. b) Vasodilate the skeletal muscles. c) Constrict blood vessels in the cardiorespiratory system. d) Relax the bronchioles.

C, Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? a) Related to difficulty swallowing b) Related to psychomotor seizures c) Related to impaired balance d) Related to visual field deficits

C, A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction

You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? a) Tetraplegia b) Paraplegia c) Autonomic dysreflexia d) Areflexia

C, Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? a) Feeding self-care deficit related to neurologic trauma b) Disturbed sensory perception (visual) related to neurologic trauma c) Risk for injury related to neurologic deficit d) Impaired verbal communication related to confusion

C, Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Weakness on one side of the body and difficulty with speech b) Footdrop and external hip rotation c) Severe headache and early change in level of consciousness d) Confusion or change in mental status

C, The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

In a biologic attack with anthrax, which ingestion route develops into the most severe form of anthrax? a) Acquired by ingestion b) Acquired by contact with body fluids or contaminated objects c) Acquired by skin infection d) Acquired by inhalation

D, The most severe form of anthrax develops by inhalation. At the onset, it may be mistaken for a cold or flu, but if it is diagnosed wrongly and untreated, the infection can progress to severe respiratory distress and almost certain death.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? a) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. b) Do nothing until the chemical agent is identified. c) Wash the wounds with soap and water and apply a barrier cream. d) Irrigate the wounds with water.

D, The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: a) NS at 60 mL/hr via an intravenous line b) Dopamine (Intropin) intravenous solution c) Morphine 2 mg intravenously d) Oxygen at 2 L/min by nasal cannula

D,In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? a) Decorticate b) Decerebrate c) Flaccid d) Normal

B, Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? a) It is the only device that can be applied for stabilization of a spinal fracture. b) It allows for stabilization of the cervical spine along with early ambulation. c) It is less bulky and traumatizing for the patient to use. d) The patient can remove it as needed.

B, Halo devices provide immobilization of the cervical spine while allowing early ambulation.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? a) To prevent secondary brain injury b) To increase cerebral perfusion pressure c) Because hypoxemia can create or worsen a neurologic deficit of the spinal cord d) So that the patient will not have a respiratory arrest

C, Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2), because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

A 65-year-old client was hit in the head with a ball and knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified? a) Chronic b) Subacute c) Acute d) Intracerebral

C, Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury

Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes? a) Scotoma b) Nystagmus c) Diplopia d) Homonymous hemianopsia

D, Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes

Which of the following measures can be used to cool a burn? a) Application of cool water b) Application of ice directly to burn c) Using cold soaks or dressings for at least 1 hour d) Wrapping the person in ice

A, Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

During a mass casualty incident (hurricane), a triage nurse participated in separating patients according to the severity of their injuries. She tagged a patient with a sucking chest wound with the color: a) red b) green c) black d) yellow

A, Red refers to a life-threatening but survivable injury. Refer to Table 56-3 in the text for an explanation of the other colors.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? a) 30-degree head elevation b) Flat c) Side-lying d) Trendelenburg's

A,For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? a) Carcinogenic b) Circulatory (distributive) c) Hypovolemic d) Obstructive

B, Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcatagories

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a) Urine output of 70 ml the first hour b) Moderate to severe pain c) Complaints of intense thirst d) Hoarseness of the voice

D, Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? a) Basilar skull fracture b) Temporal skull fracture c) Frontal skull fracture d) Occipital skull fracture

A, A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone (see Fig. 68-2). Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea)

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? a) An epidural hematoma b) An intracerebral hematoma c) An extradural hematoma d) A subdural hematoma

B, Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? a) Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. b) Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. c) Remove his burned pants so that the air can help cool the wound. d) Have someone assist him into a bath of cool water, where he can wait for emergency personnel.

D, After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process

A nurse on the neurological unit is caring for a client with a basilar skull fracture. Which high-risk nursing diagnosis is appropriate for this client? a) Risk for meningeal infection b) Risk for impaired skin integrity c) Risk for disturbed sleep pattern d) Risk for falls

A, Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or nose. Drainage of cerebrospinal fluid is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? a) 70% b) 50% c) 40% d) 60%

A, Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70% (Ramos & Azevedo, 2010).

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? a) Lactated Ringer's b) Dextran c) Albumin d) 0.9% sodium chloride

A, Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

Which of the following is a late symptom of spinal cord compression? a) Paralysis b) Urinary incontinence c) Urinary retention d) Fecal incontinence

A, Later symptoms include evidence of motor weakness and sensory deficits progressing to paralysis. Early symptoms associated with spinal cord compression include bladder and bowel dysfunction (urinary incontinence or retention; fecal incontinence or constipation)

A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client? a) Magnetic resonance imaging b) Ultrasonography c) Computed tomography d) Core needle biopsy

A, Magnetic resonance imaging is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? a) "The client is unaware of his left side. You should approach him on the right side." b) "The client is unaware of his left side. You need to encourage him to interact from this side." c) "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." d) "This condition is temporary."

A, The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his nonaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a) Encourage the family to touch and talk to the client. b) Inform the family that everything is being done to assist with the client's survival. c) Open up discussion among the family members about nursing home placement. d) Contact a spiritual advisor to provide comfort to the family.

A, The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? a) Use strict hand hygiene techniques. b) Insert indwelling catheters for incontinent patients. c) Administer prophylactic antibiotics for all patients at risk. d) Have patients wear masks in the health care facility.

A, The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques (Fried et al., 2011). Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. a) Hypertension b) Bradypnea c) Tachycardia d) Hypotension e) Bradycardia

A,B,E The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? a) Body temperature readings all within normal limits b) A urine output consistently above 40 ml/hour c) A weight gain of 4 lb (2 kg) in 24 hours d) An electrocardiogram (ECG) showing no arrhythmias

B, In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicator

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific patient management and medications to combat the virus, bacteria, or toxin. Which of the following statements reflect the patient management of variola virus (smallpox)? a) Acyclovir is effective against smallpox. b) Smallpox spreads rapidly and requires immediate isolation. c) Smallpox is spread by inhalation of spores. d) A vaccination is effective only if administered within 12 to 24 hours of exposure.

B, Smallpox is spread by droplet or direct contact. No antiviral agents are effective against smallpox; however, vaccination within 2 to 3 days of exposure is protective. It spreads rapidly and requires immediate isolation. Even in death, the disease can be transmitted. Vaccination within 2 to 3 days of exposure of the smallpox virus is protective. In 4 to 5 days, vaccination may prevent death and should be administered with vaccinia immune globulin.

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? a) Carotid ultrasound study b) Noncontrast computed tomogram c) Transcranial Doppler flow study d) 12-lead electrocardiogram

B, The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis? a) A decreased body temperature will signal the need to cover the client. b) An elevated body temperature indicates infection. c) An elevated temperature indicates cerebellum malfunction. d) The stroke may have impacted the body's thermoregulation centers.

D

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injuries? a) Significant and require medical care, but can wait hours without threat to life or limb b) Life-threatening but survivable with minimal intervention c) Extensive and chances of survival are unlikely even with definitive care d) Minor and treatment can be delayed hours to days

D, A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days. A red triage tag (priority 1 or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2 or delayed) indicates injuries that are significant and require medical care, but can wait hours without threat to life or limb. A black triage tag (priority 4 or expectant) indicates injuries that are extensive and chances of survival are unlikely even with definitive care.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Calls the Rapid Response Team b) Re-assesses the vital signs c) Contacts the admitting physician d) Administers oxygen by nasal cannula at 2 liters per minute

D, The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? a) Slow, shuffling gait b) Dysphagia and dysphonia c) Dementia d) Rapid, jerky, involuntary movements

D, The most prominent clinical features of the disease are chorea rapid, jerky, involuntary, purposeless movements), impaired voluntary movement, intellectual decline, and often personality changes (Aubeeluck & Wilson, 2008)

The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding? a) Dysphonia b) Dysphagia c) Micrographia d) Hypokinesia

A, Dysphonia (voice impairment or altered voice production) may occur as a result of weakness and incoordination of the muscles responsible for speec

Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage? a) Priority 1 b) Priority 4 c) Priority 3 d) Priority 2

B, Triage category "Expectant" is priority 4 (black) and applies to patients with injuries that are extensive and whose chances of survival are unlikely even with definitive care, such as unresponsive patients with penetrating head wounds, high spinal cord injuries, and wounds involving multiple anatomic sites and organs

Which of the following is accurate regarding topical antibacterial therapy? a) They sterilize the wound. b) They are effective against gram-negative organisms. c) They lose their effectiveness over time. d) They are systemically toxic

B,Topical antibacterial therapy is effective against gram-negative organisms and even fungi. They do not sterilize the wound; they simply reduce the number of bacteria. They penetrate the eschar but are not systemically toxic. They do not lose their effectiveness, which would allow another infection to develop.

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? a) A weak and thready pulse b) A slow and imperceptible pulse c) A slow but steady pulse d) A rapid, bounding pulse

D, A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular

A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Positive Babinski's reflex along with spastic extremities b) Spasticity of all four extremities c) Hyperreflexia along with spastic extremities d) Absence of reflexes along with flaccid extremities

D, During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." b) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing."

A, Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to: a) increase cardiac output. b) treat hypotension. c) treat hypertension. d) prevent sinus bradycardia.

A, Dobutamine increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure

Which type of shock occurs from an antigen-antibody response? a) Anaphylactic b) Neurogenic c) Septic d) Cardiogenic

A, During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has? a) Ischemic b) Hemorrhagic c) Right-sided d) Left-sided

A, Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. Options B, C, and D are incorrect.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? a) Related to femoral artery occlusion b) Related to fat emboli c) Related to infection d) Related to circumferential eschar

D, As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion

The daughter of a patient with Huntington's disease asks the nurse what the risk is of her inheriting the disease. What is the best response by the nurse? a) "The disease is inherited and all offspring of a parent will develop the disease." b) "If one parent has the disorder, there is a 50% chance that you will inherit the disease." c) "If one parent has the disorder, there is an 75% chance that you will inherit the disease." d) "The disease is not hereditary and therefore there is no risk to you."

B, Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. The disease affects approximately 1 in 10,000 men or women of all races at midlife. It is transmitted as an autosomal dominant genetic disorder; therefore, each child of a parent with Huntington disease has a 50% risk of inheriting the disorder (Ha & Fung, 2012)

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? a) Surgical wound infection b) This is a normal occurrence after an endarterectomy and would not be a concern. c) Bleeding from the endarterectomy site d) A thrombus formation at the site of the endarterectomy

D, Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body.

A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches? a) The tumor is shrinking. b) Migraines c) Dehydration d) Increased intracranial pressure

D, Headache, although not always present, is most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumor invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor, leading to increased intracranial pressure.

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? a) 18% b) 27% c) 30% d) 36%

D, The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area

The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF? a) 35 to 45 mL/100 g/min b) 35 to 45 mL/100 g/min c) 45 to 50 mL/100 g/min d) 15 to 20 mL/100 g/min

D

During a mass casualty event, a person whose injuries are extensive and whose chances of survival are unlikely even with definitive care would receive which color tag? a) Red b) Yellow c) Green d) Black

D, A black tag means expectant death, and that the injuries are extensive and chances of survival are unlikely even with definitive care. A green tag is used when injuries are minor and treatment can be delayed hours to days. A red tag means that the person's injuries are life-threatening but survivable with minimal intervention. A yellow tag indicates a person whose injuries are significant and require medical care, but can wait hours without threat to life or limb

After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? (Select all that apply.) a) Poor abstract reasoning b) Decreased attention span c) Expressive aphasia d) Short- and long-term memory loss e) Paresthesias

a,b,d Cognitive deficits associated with stroke include short- and long-term memory loss, decreased attention span, and poor abstract reasoning. Expressive aphasia is a verbal deficit, not a cognitive deficit. Paresthesias are sensory deficits, not cognitive deficits.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? a) Dextrose 5% in water (D5W) b) Lactated Ringer's solution c) Normal saline solution with 20 mEq of potassium per 1,000 ml d) Albumin

b,Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental

Which of the following is the analgesic of choice for burn pain? a) Demerol b) Fentanyl c) Morphine sulfate d) Tylenol with codeine

c, Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? a) Superficial b) Deep partial-thickness c) Superficial partial-thickness d) Full-thickness

d A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

The nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is: a) Vertigo and fainting. b) Unilateral loss of motor coordination. c) Sharp, unrelenting headaches. d) Simple to generalized seizures.

d, Seizures are usually the first symptom of a brain tumor.

The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute? a) Encourage the client to eat semisolid foods and cold foods. b) Encourage the client to drink hot liquids. c) Encourage the client to eat tepid foods. d) Encourage the client to eat solid foods.

A

The nurse is triaging people that have been involved in a bus accident. A triaged patient with psychological disturbances would be tagged with which color? a) Green b) Red c) Black d) Yellow

A

Which Glasgow Coma Scale score is indicative of a severe head injury? a) 13 b) 9 c) 7 d) 11

C, 7 A score of 8 or less is generally accepted as indicating a severe head injury

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? a) Dizziness and tinnitus b) Numbness of an arm or leg c) Severe headache d) Double vision

C, The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.

Which of the following types of skull fractures may be evident by Battle's sign? a) Comminuted b) Depressed c) Simple d) Basilar

D, A clinical manifestation of a basilar skull fracture is the Battle's sign (an area of ecchymosis may be seen over the mastoid). A simple (linear) fracture is a break in continuity of the bone. A comminuted skull fracture refers to a splintered fracture line. When bone fragments are embedded into the brain tissue, the fracture is depressed.