Test 4
3. A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a. Blood glucose 43 mg/dL b. Blood glucose 524 mg/dL c. HCO3 10 mEq/L d. PaCO2 37 mm Hg e. pH 7.23
ANS: B, C, E The patient is presenting with laboratory evidence of diabetic ketoacidosis. Diabetic ketoacidosis is characterized by hyperglycemia and low bicarbonate levels, low CO2, and low pH. A blood glucose of 43 mg/dL is indicative of hypoglycemia. The reported carbon dioxide level is normal and is not consistent with acute DKA, for which compensatory tachypnea would be expected along with a low PaCO2.
7. A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.) a. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c. Discontinue the insulin pump by removing the infusion set catheter. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.
ANS: B, D, E This patient experienced a severe hypoglycemic episode. The patient is at risk for this because of a history of autonomic neuropathy as evidenced by gastroparesis, which causes erratic gastric emptying and glucose absorption, and renal insufficiency, which can result in erratic clearance of insulin. Patients with hypoglycemia unawareness should increase blood glucose monitoring; carry a glucagon emergency kit and instruct a family member of friend on administration; monitor before high-risk activities such as driving and exercising; and use caution with alcohol ingestion. Glucagon or 50% dextrose is administered for severe hypoglycemic episodes when a patient is unconscious or extremely uncooperative. Oral glucose replacement may be dangerous in a severe reaction because of the risk of aspiration. Mild and moderate hypoglycemic reactions should be managed with oral glucose replacement. Insulin pump therapy may be suspended temporarily during a hypoglycemic episode but should not be discontinued. The infusion set catheter should not be removed during a hypoglycemic episode.
17. The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance is: a. fluid volume excess. b. hyperglycemia. c. hyperkalemia d. hypernatremia
ANS: C Adrenal insufficiency may be characterized by inadequate amounts of cortisol and aldosterone. Aldosterone acts to retain sodium, resulting is water retention and potassium loss. Inadequate levels of aldosterone therefore result in hyponatremia, fluid loss, and hyperkalemia. Inadequate cortisol levels may cause weight loss, weakness, and hypoglycemia. Fluid volume deficit may accompany adrenal crisis as a result of sodium loss from decreases in cortisol and aldosterone. Hypoglycemia may accompany adrenal crisis as a consequence of inadequate amounts of cortisol, which limits gluconeogenesis. Hyponatremia may accompany adrenal crisis because of sodium losses secondary to aldosterone insufficiency that often accompanies the condition.
16. The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patients general orientation. c. Determine the patients drug allergies. d. Determine the time of symptom onset.
ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.
2. In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Dolls eyes absent indicate a disruption in normal brainstem processing. b. Dolls eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.
ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (dolls eye): turn the patients head quickly from side to side while holding the eyes open. Note movement of eyes. The dolls eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.
30. After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F
ANS: D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104 F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis and droplet precautions are appropriate for a patient with bacterial meningitis.
19. An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? a. Elevated adrenocorticotropic hormone b. Elevated cortisol levels c. Elevated T3 and T4 d. Elevated thyroid-stimulating hormone
ANS: D Thyroid hormones are low in myxedema. Thyroid-stimulating hormone is usually high in relation to the feedback mechanisms for hormone regulation if myxedema is caused by primary hypothyroidism. Elevated adrenocorticotropic hormone may be seen in pituitary conditions or adrenal insufficiency. Elevated cortisol levels accompany Cushings syndrome. Elevated T3 and T4 levels are consistent with hyperthyroidism.
9. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patients airway patency. b. Elevate the head of the patients bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.
ANS: A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patients airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority.
17. Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg
ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.
15. A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose648 mg/dL pH6.88 PaCO220 mm Hg PaO295 mm Hg HCO3 undetectable Anion gap>31 Na+127 mEq/L K+ 3.5 mEq/L Creatinine1.8 mg/dL After the patients airway and ventilation have been established, the next priority for this patient is: a. administration of a 1-L normal saline fluid bolus. b. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. c. administration of 20 mEq KCl in 100 mL. d. IV push administration of 1 amp of sodium bicarbonate.
ANS: A After airway is established, the next priority in management of DKA is fluid resuscitation with 1 liter of normal saline over 1 hour. The fluid resuscitation should begin prior to administration of insulin. Potassium may be added to fluid replacement bags after the first liter of normal saline has infused, provided that the serum potassium is greater than 3.3 mEq/L. Although bicarbonate replacement is indicated in this clinical situation, the bicarbonate is administered by infusion, not by IV push, until the pH exceeds 7.0.
27. The nurse is caring for a patient who suffered a head trauma following a fall. The patients heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? a. Cerebral salt wasting b. Diabetes insipidus c. Syndrome of inappropriate secretion of antidiuretic hormone d. Thyroid storm
ANS: A Cerebral salt wasting may occur after head trauma and is characterized by low sodium in the face of classic physical and laboratory signs of fluid volume deficit or dehydration, including tachycardia, hypotension, dry mucous membranes, weight loss, and poor skin turgor. The patient also may experience the classic signs of hyponatremia, including a serum sodium less than 135 mg/dL, confusion, lethargy, seizures, and coma. Diabetes insipidus is characterized by clinical signs of dehydration with elevated serum sodium. SIADH is characterized by hyponatremia and fluid volume overload. Thyroid storm would not directly affect sodium levels.
7. The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patients urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing: a. diabetes insipidus. b. diabetic ketoacidosis. c. hyperosmolar hyperglycemic syndrome. d. syndrome of inappropriate secretion of antidiuretic hormone.
ANS: A Diabetes insipidus results in large volumes of urine; dehydration and hypovolemia can result. Head trauma and resulting increased intracranial pressure are potential causes of diabetes insipidus. High urine output following head trauma is associated with diabetes insipidus. Even though hyperosmolar hyperglycemic syndrome results in osmotic diuresis, the cause is a deficiency in insulin in type 2 diabetes, not head trauma. SIADH may occur with head trauma but results in reduced urine output and, potentially, hypervolemia.
31. The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports prior to use. d. Dispose of all bloody dressings in biohazard bags.
ANS: A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.
18. A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? a. Atrial fibrillation b. Idioventricular rhythm c. Junctional rhythm d. Sinus bradycardia
ANS: A Increased heart rate and tachydysrhythmia, including atrial fibrillation, may accompany thyroid storm. Bradycardiac rhythms may be suggestive of hypothyroidism.
21. Which of the following would be seen in a patient with myxedema coma? a. Decreased reflexes b. Hyperthermia c. Hyperventilation d. Tachycardia
ANS: A Myxedema coma is characterized by a hypometabolic state, and all body functions are slowed including cardiovascular function, decreased gastrointestinal mobility, cold intolerance, and diminished reflexes. Hyperthermia is characteristic of thyroid storm. Hyperventilation is characteristic of thyroid storm and diabetic ketoacidosis. Tachycardia is characteristic of thyroid storm.
1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patients plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range of motion to extremities d. Frequent oropharyngeal suctioning
ANS: A Nurses complete neurological assessments based on ordered frequency and the severity of the patients condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patients plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patients plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated.
6. A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? a. He will go into adrenal crisis. b. He will go into thyroid storm. c. His autoimmune disease will go into remission. d. Nothing; it is appropriate to stop the medication for 3 days.
ANS: A Patients on long-term corticosteroid therapy are at high risk for adrenal crisis, because therapy suppresses the endogenous production of steroids. Adrenal crisis may be precipitated by sudden withdrawal of glucocorticoid therapy. Thyroid storm may occur when antithyroid medications are suddenly withdrawn. Rheumatoid arthritis is likely to exacerbate with the withdrawal of glucocorticoids. Adrenal crisis may occur shortly after withdrawal of glucocorticoids.
21. The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous
ANS: A The patients GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.
13. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patients mouth and insert a padded tongue blade. d. Restrain the patients extremities until the seizure subsides.
ANS: A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patients jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care.
4. What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) a. Altered sleep/rest patterns b. Eating disorder c. Exposure to influenza d. High levels of stress e. Lack of financial resources
ANS: A, B, D, E Psychosocial factors may lead to changes in diabetes self-management practices that precipitate diabetic ketoacidosis. Eating disorders may complicate 20% of recurrent cases of DKA in young women. Changes in sleep patterns and psychosocial stressors may lead to increased insulin demands in the face of declining self-care practices. Financial and time limitations impacted the ability to monitor for changes in control. Exposure to influenza is a physiological factor; it would not be a psychosocial factor associated with DKA.
5. Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) a. Heredity b. Medications, including phenytoin (Dilantin) and lithium carbonate c. Meningitis d. Pituitary tumors e. Sickle cell disease
ANS: A, B, E Nephrogenic diabetes insipidus occurs when adequate amounts of antidiuretic hormone are produced with limited renal response. Causative factors for nephrogenic diabetes insipidus are heredity, preexisting renal disease, multisystem diseases such as multiple myeloma and sickle cell disease, chronic electrolyte disturbances, and medications. Meningitis may result in neurogenic diabetes insipidus. Pituitary tumors may result in neurogenic diabetes insipidus.
2. Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) a. ADH deficiency b. ADH excess c. ADH insensitivity d. ADH replacement therapy e. Water deprivation
ANS: A, C Diabetes insipidus is caused by either a deficiency in ADH production (neurogenic) or impaired renal response to ADH (nephrogenic). ADH excess is characteristic of syndrome of inappropriate secretion of antidiuretic hormone. ADH replacement therapy is a treatment for neurogenic diabetes insipidus. Water deprivation would result in increased ADH secretion and further augment dehydration associated with diabetes insipidus.
3. The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patients plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.
ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.
1. Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) a. Administer levothyroxine (Synthroid) as ordered. b. Encourage the intake of foods high in sodium. c. Initiate passive rewarming interventions. d. Monitor airway and respiratory effort. e. Monitor urine osmolality.
ANS: A, C, D Myxedema coma is a severe manifestation of hypothyroidism. Treatment entails replacement of thyroid hormone, airway management related to respiratory depression and potential airway obstruction related to tongue edema, thermoregulation, management of edema and congestive heart failure symptoms, and patient education. Edema may accompany myxedema and necessitate use of sodium restriction. Urine osmolality is monitored in conditions that affect antidiuretic hormone levels.
18. The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.
ANS: B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patients airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.
16. Acute adrenal crisis is caused by: a. acute renal failure. b. deficiency of corticosteroids. c. high doses of corticosteroids. d. overdose of testosterone.
ANS: B An adrenal crisis occurs because of a lack of corticosteroids. This may be due to lack of endogenous cortisol production, lack of ACTH production, or inhibition of natural cortisol production by exogenous cortisol administration. Acute renal failure would not be associated with adrenal crisis. High doses of corticosteroids are associated with Cushings syndrome. Testosterone overdose would not be associated with adrenal crisis. Steroid hormones may possess some corticoid properties.
15. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the physician of the patients blood pressure.
ANS: B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distention. Other causes that should be ruled out prior to pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow deep breathes will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician.
4. Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a. Activity intolerance b. Fluid volume deficient c. Hyperthermia d. Impaired nutrition, more than body requirements
ANS: B Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia; therefore, fluid volume deficit is a priority nursing diagnosis. Even though activity intolerance is a potential nursing diagnosis related to the fatigue associated with metabolic changes in hyperglycemic conditions, it is not a first priority. Hyperthermia is associated with thyroid crisis. Although overweight and obesity are risk factors for type 2 diabetes, during metabolic crisis, the patient has inadequate energy available to tissues because of limited availability and poor utilization of insulin.
1. A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of: a. adrenal insufficiency. b. diabetic ketoacidosis. c. hyperosmolar, hyperglycemic state. d. hypoglycemia.
ANS: B If the insulin pump fails, the patient with type 1 diabetes will have a complete interruption of insulin delivery; diabetic ketoacidosis will occur. Adrenal insufficiency would not result from insulin pump failure. Hyperosmolar, hyperglycemic state is a hyperglycemic complication associated with type 2 diabetes; this patient has type 1 diabetes. Interruption of insulin delivery in type 1 diabetes would result in hyperglycemia, not hypoglycemia.
19. The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.
ANS: B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
23. The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patients blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the physician of the BP. d. Begin weaning the infusion.
ANS: B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patients blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the physician of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.
22. The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? a. Congestive heart failure b. Hypovolemic shock c. Infection d. Volume overload
ANS: B Pituitary surgery or manipulation of the pituitary stalk during surgery may precipitate diabetes insipidus. Profound diuresis that accompanies diabetes insipidus may result in hypovolemic shock. Fluid volume deficit, not overload, accompanies diabetes insipidus. Increased risk of infection may accompany hyperglycemia and elevated cortisol levels. Fluid volume overload is more characteristic of SIADH.
28. A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine (Lantus) and insulin aspart (NovoLog). How should the nurse manage this transition in insulin delivery? a. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. b. Administer the insulin glargine and discontinue the IV infusion in several hours. c. Discontinue the IV infusion and administer the insulin aspart with the next meal. d. Discontinue the IV infusion and administer the Lantus insulin at bedtime.
ANS: B Subcutaneous insulin should be administered 1 to 4 hours before discontinuing the intravenous infusion to allow the patient to reach adequate plasma insulin levels to prevent redevelopment of DKA. Continuation of the insulin infusion in conjunction with the long-acting insulin glargine would result in hypoglycemia. Discontinuation of intravenous insulin prior to administration of subcutaneous insulin would result in reoccurrence of DKA in a patient with type 1 diabetes.
14. An individual with type 2 diabetes who takes glipizide (Glucotrol) to control her blood glucose has begun a formal exercise program at a local gym. While exercising on the treadmill, she becomes pale, diaphoretic, and shaky. She has a headache and feels as though she is going to pass out. What is the individuals priority action? a. Drink additional water to prevent dehydration. b. Eat something with 15 g of simple carbohydrates. c. Go to the first aid station to have glucose checked. d. Take another dose of the oral agent.
ANS: B The patient is displaying classic symptoms of hypoglycemia. The patient is on sulfonylurea therapy, which carries the risk of hypoglycemia. The walking may be more exercise than she is used to and may thereby cause hypoglycemia. Fifteen grams of carbohydrate is appropriate for initial management of hypoglycemia. Hypoglycemia does not place the patient at risk for dehydration. The patient requires immediate treatment and could pass out while going to the first aid station. It cannot be assumed that the gym has access to diabetes treatment supplies. Additional doses of oral diabetes medications should not be taken without consulting the healthcare team. An additional dose of glipizide could promote further hypoglycemia.
29. The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push
ANS: B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.
6. The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a. 18-year-old male who has undergone surgical correction of a fractured femur b. 29-year-old female who is undergoing evaluation for pheochromocytoma c. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)
ANS: B, C, D, E Risk factors for development of stress-induced hyperglycemia are a prior history of diabetes or hyperglycemia; obesity; pancreatitis; cirrhosis; glucocorticoids; excess epinephrine; advanced age; nutrition support; and various medications. The young male with the fractured femur is at low risk for stress-induced hyperglycemia.
32. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5 F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bedrest at all times.
ANS: C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation such photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bedrest are all appropriate nursing interventions but are not the priorities in this scenario.
2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg
ANS: C CPP = MAP ICP. In this case, CPP = 108 mm Hg 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.
22. The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5 F. Which physician order should the nurse institute first? a. Blood cultures (2 specimens) for temperature > 101 F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours
ANS: C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.
8. The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)
ANS: C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.
5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patients left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.
ANS: C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.
5. The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is: a. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 50 to 75 mg/dL compared with admitting values. d. less than 200 mg/dL.
ANS: C Initial insulin infusions should be administered with a target blood glucose reduction of 50 to 75 mg/dL per hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus, controlled reduction of glucose is required.
14. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
ANS: C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35-45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.
10. A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium.
ANS: C Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid balance has been restored and glucose has returned to more normal levels. Insulin administration used in the treatment of diabetic ketoacidosis further promotes lowering of potassium as the electrolyte is relocated to the cellular bed. Calcium levels do not drastically change in hyperosmolar states and are not a primary concern unless phosphate replacement is initiated. Chloride levels typically follow sodium levels and normalize with fluid replacement. Sodium levels may initially be elevated as a result of dehydration but will be corrected with fluid replacement.
24. Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? a. Fasting blood glucose 156 mg/dL b. Serum potassium 5.8 mEq/L c. Serum sodium 115 mEq/L d. Serum sodium 152 mEq/L
ANS: C SIADH causes a dilutional hyponatremia, and central nervous system symptoms can occur. A low serum sodium (below 135 mEq/L) may accompany the syndrome. Glucose elevation is not a classic sign of SIADH. Hyperkalemia does not accompany the dilutional hyponatremia of SIADH. Serum sodium levels are typically lower in the dilutional hyponatremia that accompanies SIADH.
3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low.
ANS: C The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range.
20. The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg
ANS: C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg 70 kg) + (5.4 mg 70 kg) 23 hours = 10,794 mg.
25. A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include: a. administration of 3% normal saline. b. administration of exogenous vasopressin. c. fluid restriction. d. low sodium diet.
ANS: C The first treatment of this condition is volume restriction; other treatments may not be needed if restrictions work. Extreme fluid restrictions (800 to 1000 mL/day) may be required in the treatment of SIADH. Hypertonic saline administration may be used to treat severe hyponatremia (serum sodium < 110 mEq/L) but is not used in most cases. The administration of hypertonic saline carries significant risk. Vasopressin replacement would provide additional ADH and further complicate SIADH. Sodium replacement may be required to treat the hemodilution associated with SIADH.
24. The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the physician. d. Assess cardiac rhythm.
ANS: C The ordered dose is an inappropriate maintenance dose. The nurse should contact the physician. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.
10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.
ANS: C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.
1. The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device prn c. Recording ICP as a mean value d. Use of a pressurized flush system e. Zero referencing the transducer system
ANS: C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.
3. Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? a. Blood glucose >1000 mg/dL b. Negative ketones in the urine c. Normal anion gap d. pH 7.24
ANS: D A pH of 7.24 is indicative of an acidotic state that may accompany diabetic ketoacidosis. Glucose values of more than 1000 mg/dL are more commonly associated with hyperosmolar hyperglycemic syndrome. Diabetic ketoacidosis is associated with positive urine ketones and an increased anion gap.
23. The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? a. Daily weight b. Fingerstick glucose c. Lung sound auscultation d. Urine osmolality
ANS: D Diabetes insipidus may result from traumatic brain injury. It results in passage of large volumes of dilute urine. Urine osmolality is low in individuals with diabetes insipidus, and urine specific gravity assessments should be incorporated into the care of at-risk patients. Even though daily weight monitoring is important in the assessment of fluid balance disorders, it is not specific in determining cause. Urine specific gravity measuring would be a more specific means of identifying diabetes insipidus. Blood glucose values would be abnormal in diabetes mellitus but not diabetes insipidus. Changes in breath sounds accompany fluid overload states such as SIADH. Diabetes insipidus is a hypovolemic condition.
2. Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? a. An 18-year-old college student with type 1 diabetes who exercises excessively b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimers disease who recently developed influenza
ANS: D Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would result in further increases in blood sugar. Some individuals with advanced Alzheimers disease cannot communicate thirst needs and may be incontinent, making hypertonic fluid loss more difficult to estimate. Uncontrolled type 1 diabetes is associated with diabetic ketoacidosis. Interruption of insulin delivery related to a missed insulin dose in type 1 diabetes creates a situation of absolute insulin deficiency in type 1 diabetes and is associated with diabetic ketoacidosis. A patient with type 2 diabetes who is new to insulin is at risk for hypoglycemia.
12. In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis
ANS: D In patients with hyperosmolar hyperglycemic syndrome (HHS), glucose is higher; osmotic diuresis is greater, resulting in higher osmolality; and ketosis is usually absent. Glucose values in HHS are typically higher than those of diabetic ketoacidosis and are not typically accompanied by ketosis.
12. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102 F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.
ANS: D In this scenario, the patients temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.
26. The nurse is providing insulin education for an elderly patient with longstanding diabetes. An order has been written for the patient to take 20 units of insulin glargine (Lantus) at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is: a. 0200. b. 0400. c. 0800. d. peakless.
ANS: D Insulin glargine (Lantus) is a long-acting insulin that has no specific peak in action. The remaining times are associated with peaks of other short-acting and intermediate-acting insulin products.
9. In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? a. Never; normal saline is the only appropriate solution in diabetes management b. When the blood sugar reaches 70 mg/dL c. When the blood sugar reaches 150 mg/dL d. When the blood glucose reaches 250 mg/dL
ANS: D Normal saline is the best initial fluid choice for management of hyperglycemic states. However, when the glucose reaches about 250 mg/dL, solutions containing dextrose are added to prevent hypoglycemia. Hypotonic solutions are required to replace intracellular fluid deficits, and dextrose is required to prevent hypoglycemia later when glucose levels reach initial targets. A glucose level of 70 mg/dL is suggestive of hypoglycemia and would require oral glucose replacement, a 50% dextrose bolus, or glucagon administration.
7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg
ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.
11. The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.
ANS: D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.
11. A patient is admitted to the oncology unit with a small cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with: a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).
ANS: D SIADH may be induced by ectopic sources of antidiuretic hormone, including small cell lung carcinoma. The clinical presentation of a dilutional hypervolemia is consistent with SIADH. Adrenal crisis is characterized by fluid loss if secondary to decreased cortisol and aldosterone levels resulting in sodium loss. Diabetes insipidus is characterized by increased urine output and is not typically caused by lung tumors. Myxedema coma, although characterized by facial and peripheral edema, does not result from small cell lung carcinoma.
4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patients head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.
ANS: D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patients plan of care; however, spacing out interventions is the priority.
20. A patient presents to the emergency department (ED) with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 104.8 F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder? a. Adrenal crisis b. Myxedema coma c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Thyroid storm
ANS: D Tachycardia, vascular collapse, rapid cardiac rhythms, congestive heart failure, and severe hyperthermia are consistent with the clinical manifestations of the hypermetabolic state of thyroid storm. Adrenal insufficiency presents with weakness, fatigue, weight loss, anorexia, abdominal pain, and hyperpigmentation. Myxedema coma is an extreme form of hypothyroidism and is characterized by signs of hypometabolism, including bradycardia, hypotension, hypothermia, cold intolerance, and neurological sluggishness. SIADH is characterized by fluid retention, hyponatremia, and hemodilution. Heat intolerance and atrial fibrillation are not typical characteristics of the condition.
6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the physician immediately.
ANS: D These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the physician is a priority given the severity in change of neurological status.
8. The nurse is providing postoperative care to a patient who underwent a transsphenoidal hypophysectomy for a benign pituitary tumor. The nurse administers replacement hydrocortisone, thyroid hormone, and vasopressin. The nurse evaluates that the vasopressin replacement is effective when: a. the patients blood glucose is 110 mg/dL. b. the patient maintains a core body temperature of 98.2 F (36.8 C). c. the patients urine specific gravity decreases. d. 2 liters of urine are produced in a 24-hour period.
ANS: D Vasopressin is administered to replace antidiuretic hormone following a hypophysectomy. Other life-sustaining hormones such as cortisol and thyroid hormone that involve a feedback system between the pituitary gland and the target gland also must be replaced. Vasopressin produces elevation of blood pressure, causes retention of fluid, and reduces urine output. The result is a decrease in serum sodium and serum osmolality secondary to hemodilution and increase in urine specific gravity. Blood glucose control is not affected by vasopressin; cortisol would directly affect blood glucose. Core body temperature would be most directly affected by thyroid hormone. Urine specific gravity would increase, not decrease, following vasopressin administration.
13. Which of the following statements is true about the medical management of diabetic ketoacidosis? a. Serum lactate levels are used to guide insulin administration. b. Sodium bicarbonate is a first-line medication for treatment. c. The degree of acidosis is assessed through continuous pulse oximetry. d. Volume replacement and insulin infusion often correct the acidosis.
ANS: D Volume replacement promotes hemodilution in the face of a hyperosmolar state. Insulin administration promotes entry of glucose into cells and relieves ketosis. As volume is replaced and glucose normalizes, the acidosis often resolves. Insulin administration, not lactate levels, is guided by blood glucose values. Sodium bicarbonate is only administered to correct severe acidosis (pH < 7.1). Degree of acidosis is assessed through arterial blood gas readings and serum ketone levels.
