405 Exam 2 (Resp, Neuro/spinal, metab, ER)

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

Approximately at the pt's lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips.

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply.

Cool, most skin (resulting from poor peripheral perfusion) Decreasing BP Increased HR Delayed capillary refill Decreasing urine volume

Which is the most common cause of spinal cord injury (SCI)?

MVA (motor vehicle crashes)

A __________ wound takes on the outline of the object causing the wound.

Patterned

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

Placing a blanket over the client An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neurologic deficit

What is the seldinger maneuver?

The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

body temp It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply.

cerebral edema ischemia infection seizures hyperthermia

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

fever and change in urine clarity Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. Suddenly, gunshots are heard. Which of the following would be the nurse's priority?

protecting themselves If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

"I can apply powder under the liner to help with sweating." Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning?

"My brother got sick like me after eating the same food." The statement about the patient's brother also being sick after eating the same food suggests food poisoning. Feeling sick to the stomach for 3 to 4 days could indicate various problems, not just food poisoning. Food tasting or looking fine does not really indicate anything definitive about the patient's condition. Most foods causing bacterial poisoning do not have unusual odor or taste. A pain in the left groin area is more suggestive of appendicitis, not food poisoning.

A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make?

"They help prevent the development of contractures." Clients are at high risk for the development of contractures as a result of disuse syndrome due to the musculoskeletal system changes brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises to prevent footdrop. Range-of-motion exercises are not done to stabilize total body functioning or restore skeletal integrity. Exercise programs are used to prepare to function in the absence of leg function.

A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them.

1. establish airway & ventilation 2. control hemorrhage 3. prevent & treat shock 4. assess for head & neck injuries 5. assess for abd, back, & extremity injuries 6. splint fractures When providing care to a patient with multiple injuries, the nurse would first establish airway and ventilation, then control hemorrhage, prevent and treat hypovolemic shock, and assess for head and neck injuries. Then the nurse would evaluate for other injuries including re-assessing the head, neck, and chest and assessing the abdomen, back, and extremities. Then the nurse would splint fractures and, lastly, perform a more thorough and ongoing examination and assessment.

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders?

1st thoracic vertebrae Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?

4% Oxygen is administered until the carboxyhemoglobin level is less than 5%.

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

Apply a clean dressing to protect the wound, elevate the site to limit the accumulation of fluid in the interstitial spaces, & splint the wound in a position of rest to prevent motion Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.

The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client?

Apply an external urinary sheath catheter A strategy the nurse can implement to prevent client injury is to use an external sheath catheter for a male client if incontinence occurs. Because prolonged use of an indwelling catheter inevitably produces infection, the client may be placed on an intermittent catheterization schedule. Opioids are contraindicated because they depress respirations, constrict the pupils, and alter responsiveness. Providing adequate lighting to prevent visual hallucinations is recommended. Repositioning the client every 2 hours maintains skin integrity.

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?

Apply elastic stockings to lower extremities To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

Apply firm pressure over the involved area or artery Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?

Applying electrocardiogram electrodes A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.

_______ is manifested as a tearing away of tissue from the supporting structures.

Avulsion

The nurse is concerned that a client with a traumatic brain injury is developing an endocrine disorder. Which assessment will the nurse complete for this client? Select all that apply.

BG urine acetone I&O serum electrolytes

What is battle sign?

Battle sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5 At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control. At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

CSF leaking from the ear The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

Delayed cap refill If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? a. Diagnostic and laboratory testing b. Assessment of peripheral pulses c. Establishing a patent airway d. Undressing the client

Diagnostic and laboratory testing Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.

Which statement reflects the nursing management of the client with a white phosphorus chemical burn?

Do not apply water to the burn Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn

A client is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will perform which of the following actions?

ET intubation Endotracheal tubes are used in cases when the client cannot be ventilated with an oropharyngeal airway, which is used in clients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?

Edema to the head with bruising of the mastoid process

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client?

Ensuring cont. ECG monitoring A hypothermic client requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the client's respiratory needs.

A nurse is performing a primary survey of a client brought to the emergency department. Which of the following would the nurse include? Select all that apply.

Establish airway patency, providing adequate ventilation, assessing neuro function The primary survey addresses airway, breathing, circulation, and disability. The nurse would establish a patent airway, provide adequate ventilation, evaluate and restore cardiac output, and determine neurologic disability by assessing neurologic function. Obtaining a complete health history and applying monitoring devices are activities involved with the secondary survey.

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Eye opening Verbal response motor response Rated on a scale from 3-15

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?

Flat, except for logrolling as needed When caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply.

Gunshot wound & knife-stab wound Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

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.

HTN (widened pulse pressure) bradycardia Bradypnea (irregular resp)

A nurse is providing care to a client who is a victim of trauma resulting from injuries sustained in a convenience store robbery. The client has been stabbed numerous times in the abdomen and chest. His shirt is bloody and torn. Which of the following would be most appropriate when collecting forensic evidence?

Hanging up any damp or wet clothing to dry before securing When collecting forensic evidence, the nurse should remove the client's clothing, being careful not to cut through or disrupt any tears, holes, blood stains or dirt present on the clothing. Each piece of clothing is put into a separate paper bag and labeled. If the clothing is wet or damp, it should be hung to dry. If a police officer is present to collect clothing or any other items from the client, each bag is labeled with the client's name, and the transfer of custody to the officer, the officer's name, date, and time are documented.

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?

Have the patient lie down and place the arm below the level of the heart. Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

Hypovolemia Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?

Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

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?

Irrigates the wound to remove debris 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.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

It results from initial damage to the brain from the traumatic event.

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?

Jaw-thrust If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates?

Nitroglycerin Nitroglycerin is indicated for use in clients who experience angina pectoris as a result of myocardial ischemia. The medication acts by decreasing blood pressure and causing arterial vasodilation permitting blood flow into the myocardium. Nitroglycerin should be given prior to any anticipated physical exertion that is likely to bring on chest pain from vasoconstriction. Vasopressin is a vasoactive medication administered to increase blood pressure in cases where clients have diabetes insipidus, a gastrointestinal bleed or in cases of septic shock. Norepinephrine raises blood pressure and is indicated for use in emergencies such as cardiac arrest or for hypovolemia. Dobutamine increased heart contractility and blood pressure to improve stroke volume in clients with congestive heart failure.

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

Pt requires TPN For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of

Pulmonary edema Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours.

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client?

Q 30 min Clients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, clients in the urgent category must be reassessed at least every 30 minutes, those in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Raise the head of the bed and place the patient in a sitting position. The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?

Rebound hypotension When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.

The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action?

Request that the pastor be present to support the family at the client bedside

The emergency nurse is preparing to triage a group of four clients who have presented to the emergency department (ED) and arrived at the same time.

Requires immediate... intervention: 46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC). 22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots. 52-year-old female client who presents with severe back pain of recent onset Can wait to be seen... 25-year-old male client who presents with a small laceration on the left upper arm (nonurgent) The 46-year-old male client with a suspected fractured leg should be seen immediately. A fracture can lead to further complications such as development of a fat embolism, which can be fatal. Stabilization and surgical intervention are needed. The 22-year-old female client needs to be seen immediately because they may be experiencing a tubal pregnancy, ovarian problem, or a miscarriage. Determination of the source of the bleeding and the etiology of the abdominal pain must be identified. The 52-year-old female client experiencing severe back pain should be seen immediately because female clients present with atypical presentations related to cardiac issues. This client may be experiencing a cardiac event, and the client should be seen immediately to determine if this is cardiac in nature.

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

Seizures Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension.

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

Spinal shock Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?

Stab A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

Stage III Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)?

Tachycardia Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration. More rapid heart rate (tachycardia) is not a component of the triad.

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Temp increase from 98 to 99.6 Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. RN monitors pt 's temp Q2-4h. If the temp increases, efforts are made to identify the cause and to control it using acetaminophen & cooling blankets to maintain normothermia.

What is the abdominal trust?

The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body.

The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart?

The client's myocardial oxygen requirements will be higher Clients with heart failure are typically hypervolemic and as a result this increases the cardiac preload. An increased fluid volume increases the stroke volume, ventricular work and myocardial oxygen requirements. Vasodilation can be a potential cause for decreased preload and afterload, not increased preload as in this case. This client would experience vasoconstriction due to the increase volume with each stroke.

What is a secondary brain injury?

The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.

What is a common source of airway obstruction in an unconscious client?

Tongue In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

Urgent

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.

Young age Male Substance abuse

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.

ask if they wana see the body, provide a private place for the fam to be together, Allow fam to express their emotions freely When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.

You are a neurotrauma 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?

autonomic dysreflexia 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 has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?

brachial The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

brushing off all traces of the chemical from the pt's skin For a chemical burn involving lye or white phosphorous, all evidence of the chemical should be brushed off the patient before any flushing occurs. These chemicals, if exposed to water, have the potential for exploding or for deepening the burn. Covering the burn area or applying ice is an inappropriate action.

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?

debriefing After serious events, critical incident stress management (CISM) is necessary to critique individual and group performance and to facilitate healthy coping. Optimally, this may consist of three steps: defusing, debriefing, and follow-up. Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time. Defusing occurs immediately after the critical incident. During this session, affected staff are encouraged to discuss their feelings about the incident and are given contact information so that they may talk to someone if they have disturbing symptoms (e.g., sleeplessness, excessive worry). Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy. Counseling or group therapy would typically occur outside the context of the stress-inducing environment. Individuals may require private counseling versus group counseling.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?

ensure a patent airway & that the pt is receiving 100% O2 Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:

famotidine (Pepcid). Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?

high-pitched noise on inhalation A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

insert NG tube Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

______ is a tear in the skin with irregular edges and vein bridging.

laceration

pain in the right shoulder can result from laceration of what organ?

liver

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

liver Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

look for signs of increased ICP igns of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:

loss of motor power and sensation in the upper extremities. Characteristics of a central cord injury include motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?

massaging the feet For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

meticulous cleanliness Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.

A family member brings a client to the ED following an apparent oxycodone overdose. The client is experiencing severe respiratory depression. Which medication will the nurse administer?

naloxone hydrochloride Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Flumazenil is a benzodiazepine antagonist. Diazepam is a benzodiazepine. N-acetylcysteine is used for acetaminophen toxicity.

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?

pain in the L shoulder Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder is consistent with a laceration of the liver. The spleen is located in the left upper quadrant, not the right. Rebound tenderness and abdominal distention are generalized signs suggesting intraperitoneal injury. Although these generalized signs may accompany a ruptured spleen, they are less specific than pain in the left shoulder.

The nurse observes that the family members of a client who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?

remorse & guilt Remorse and guilt are natural processes of the stages of a crisis and should be facilitated for the family members to process the crisis. The family's sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety.

A nurse is establishing a patient's airway. Which action would the nurse perform first?

repositioning the pt's head Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust maneuver, or insertion of an artificial airway.

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.

respiratory irregularities slow bounding pulse widened pulse pressure In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. This is typically accompanied by a slow, bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. A sympathetically mediated response causes an increase in the systolic blood pressure, with a widening of the pulse pressure and cardiac slowing.

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the

spleen The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a client with bleeding from a ruptured spleen.

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

subdural hematoma A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the 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 client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

suction airway Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions. To prevent hypoxemia, the client may need more oxygen than is available in the room air. An endotracheal tube provides an airway from the nose or mouth to an area above the mainstem bronchi. Mechanical ventilation provides a means to regulate the respiratory rate, volume of air, and percentage of oxygen when a client fails to breathe independently.

The nurse is caring for a client admitted with a drug overdose. What is the nurse's priority responsibility in caring for this client?

support the pt's resp & cardiovascular function ABCs. Tx goals for pt w/ drug OD are to support the resp and cardiovascular functions, to enhance clearance of the agent, & to provide for safety of the pt and staff. Of these responsibilities, however, support of vital physiologic function is a priority.

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?

take daily wts 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.

A nurse working in an emergency department is responsible for determining the severity of the patients' problems and how fast each needs to be seen. The nurse is implementing which of the following?

triage The nurse is performing triage, which sorts patients into groups based on the severity of their health problems and the immediacy with which these problems need to be treated. Referral involves communicating with other health care delivery service providers to assist the patient with meeting his or her needs. Discharge planning involves actions to get the patient ready to leave the facility. Crisis intervention involves actions to alleviate the high level of stress and to promote effective coping with challenging life events.

Which category of triage encompasses clients with serious health problems that are not immediately life threatening?

urgent Urgent clients have serious health problems that not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority with life-threatening conditions and they must be seen immediately. Nonurgent clients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

What is the Head-tilt chin-lift maneuver?

used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.