412 Exam 3
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? "Emotional lability is common after a stroke, and it usually improves with time." "You sound stressed; maybe using some stress management techniques will help." "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?"
"Emotional lability is common after a stroke, and it usually improves with time."
A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? "Monitor urine output every hour." "Infuse I.V. fluids at 83 ml/hour." "Administer oxygen by nasal cannula at 3 L/minute." "Draw samples for hemoglobin and hematocrit every 6 hours."
"Infuse I.V. fluids at 83 ml/hour."
The nurse is administering colloids to a client during the first 6 hours of septic shock. What is the client's central venous pressure reading goal? 1 to 3 mm Hg 4 to 5 mm Hg 6 to 7 mm Hg 10 to 12 mm Hg
10 to 12 mm Hg
The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? 20 cm H2O 15 cm H2O 10 cm H2O 5 cm H2O
20 cm H2O
The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate? 1:1 2:1 3:1 4:1
3:1
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A full liquid diet Isotonic enteral nutrition every 6 hours An infusion of crystalloids at an increased rate of flow A continuous infusion of total parenteral nutrition
A continuous infusion of total parenteral nutrition
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: Valvular damage. Cardiomyopathies. A myocardial infarction. Arrhythmias.
A myocardial infarction.
When a client who experienced thoracic trauma is admitted to the ICU the nurse notes that their chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A chest tube A tracheostomy An endotracheal tube A feeding tube
A tracheostomy
Your client is in shock. You are to assess this client for inadequate oxygen delivery to the tissues. What is the first sign you will observe in the initial stages of shock? Cyanosis Decreased respiratory rate Altered cerebral function Increased body temperature
Altered cerebral function
The nurse in the emergency department is caring for a client recently admitted with a likely myocardial infarction (MI). The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at an increased risk for MI due to which factor? Arrhythmias Elevated B-natriuretic peptide (BNP) Use of thrombolytics Dehydration
Arrhythmias
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? Putting slippers on the client's feet Crossing the client's ankles every 2 hours Placing hand rolls on the balls of each foot Attaching braces or splints to each foot and leg
Attaching braces or splints to each foot and leg
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To increase cerebral perfusion pressure To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
Hemorrhagic
Bleeding in the brain
Which of the following is a clinical characteristic of neurogenic shock? Bradycardia Tachycardia Cool skin Moist skin
Bradycardia
Embolic Stroke (Ischemic)
Clot formed elsewhere and traveled to brain and got lodged blocked blood blow
A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as Cardiogenic Compensatory Progressive Circulatory
Compensatory
A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur? Compensation Irreversible Early Decompensation
Decompensation
A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? Crackles Rhonchi Decreased breath sounds Wheezes
Decreased breath sounds
Vertigo
Feel like room is spinning, not the same as being dizzy,
A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs? Gastrostomy tube Nasogastric tube Nasointestinal (NI) tube Salem sump tube
Gastrostomy tube
Which sign would be considered a late indicator of increased intracranial pressure? Tachycardia Right-sided heart failure Narrow pulse pressure High mean arterial pressure
High mean arterial pressure
Which disturbance results in loss of half of the visual field? Homonymous hemianopsia Diplopia Nystagmus Anisocoria
Homonymous hemianopsia
The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor? Hypothermia Bradycardia Coffee ground emesis Pain
Hypothermia
nystagmus
Involuntary rapid eye movements
The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? It slows the proliferation of bacteria and viruses during shock. It decreases the energy expended through the functioning of the GI system. It assists in expanding the intravascular volume of the body. It promotes GI function through direct exposure to nutrients.
It promotes GI function through direct exposure to nutrients.
Anomia
Loss of the ability to name objects or retrieve names of people
A client has a diagnosis of HIV. Which statement would concern the nurse? I use the same bathroom as the rest of my family. I enjoy preparing meals for my family. I often spend time with and hug my young nieces and nephews. My dog likes to roam the neighborhood and often eats from garbage cans.
My dog likes to roam the neighborhood and often eats from garbage cans.
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Oxygen-induced hypoventilation Oxygen toxicity Oxygen-induced atelectasis Hypoxia
Oxygen toxicity
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated? Performing frequent oral care Maintaining the client in a supine position Suctioning the client every 15 minutes unless contraindicated Administering prophylactic antibiotics, as prescribed
Performing frequent oral care
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. Lowered systolic blood pressure Respiratory irregularities Slow bounding pulse Increased cerebral perfusion Widened pulse pressure
Respiratory irregularities Slow bounding pulse Widened pulse pressure
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Oxygen saturation of 93% Runs of ventricular tachycardia Blood pressure remains stable
Runs of ventricular tachycardia
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Tension pneumothorax Cardiac tamponade Flail chest
Tension pneumothorax
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? "The tube will allow air to be restored to the lung." "The tube will drain secretions from the lung." "The tube will provide a route for medication instillation to the lung." "The tube will drain air from the space around the lung."
The tube will drain air from the space around the lung."
As the nurse, you are clients' first line of defense in treating shock. When assessing a client for early signs of shock, what would you assess first? B/P, Urine output, and mentation Vital signs, skin color, and temperature Mental status, skin color, and dyspnea Temperature, level of consciousness, and airway obstruction
Vital signs, skin color, and temperature
A client in the ICU has had an endotracheal tube in place for 3 weeks. The health care provider has ordered that a tracheostomy tube be placed. The client's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? "The physician may feel that mechanical ventilation will have to be used long-term." "Long-term use of an endotracheal tube diminishes the normal breathing reflex." "When an endotracheal tube is left in too long it can damage the lining of the windpipe." "It is much harder to breathe through an endotracheal tube than a tracheostomy."
When an endotracheal tube is left in too long it can damage the lining of the windpipe."
dysphagia
difficulty swallowing
What is the major clinical use of dobutamine? increase cardiac output. prevent sinus bradycardia. treat hypotension. treat hypertension.
increase cardiac output.
ataxia
lack of muscle coordination, and control, they can move but muscle movement can be jerky or uncoordinated. awkward gait, balance affected, ability to walk.
Homonymous hemianopsia
loss of half of the field of view on the same side in both eyes, Tunnel Vision
A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: 48 mm Hg. 52 mm Hg. 68 mm Hg. 88 mm Hg.
52 mm Hg.
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? 50 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg
70 mm Hg
Which are considered the best ways to engage in risk-free or low-risk behavior of contracting HIV? Select all that apply. Abstinence Mutually sexual monogamy between two uninfected individuals Using lambskin condoms instead of latex Using oil-based lubricants instead of water based Only engaging in sexual relations with individuals who have never had a sexually transmitted infection (STI)
Abstinence Mutually sexual monogamy between two uninfected individuals Only engaging in sexual relations with individuals who have never had a sexually transmitted infection (STI)
A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? Respiratory distress and projectile vomiting Bradycardia and hypertension Tachycardia and agitation Third-spacing and hyperthermia
Bradycardia and hypertension
The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology? Carboxyhemoglobin level Brain natriuretic peptide (BNP) level C-reactive protein (CRP) level Complete blood count
Brain natriuretic peptide (BNP) level
The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock? Increased hunger Decreased thirst Decreased urinary output Increased capillary perfusion
Decreased urinary output
A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. Hypovolemia Difficulty breathing Cardiovascular overload Pulmonary edema Hypoglycemia
Difficulty breathing Cardiovascular overload Pulmonary edema
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stress ulcer Disseminated intravascular coagulation (DIC) Septicemia Stevens-Johnson syndrome from the administration of antibiotics
Disseminated intravascular coagulation (DIC)
diplopia
Double vision, Blurry vision.
An elderly patient is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the patient's frustration? A Facilitate communication between the different professionals and attempt to coordinate care. B Teach the patient about the unique scope and focus of each member of the healthcare team. C Modify the patient's plan of care to better reflect the commonalities between the different disciplines. D Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.
Facilitate communication between the different professionals and attempt to coordinate care.
A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? Flail chest Cardiac tamponade Pulmonary contusion Simple pneumothorax
Flail chest
A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: Coma Absence of brain stem reflexes Apnea Glasgow Coma Scale of 6
Glasgow Coma Scale of 6
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? Increased ICP Exacerbation of uncontrolled hypertension Infection Increase in cerebral perfusion pressure
Increased ICP
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? The pupils are dilated and fixed. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). Increased ICP is 12 mm Hg. Cerebral perfusion pressure (CPP) is 21 mm Hg.
Increased ICP is 12 mm Hg.
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Ineffective cerebral tissue perfusion related to increased intracranial pressure Disturbed thought processes related to brain injury Ineffective airway clearance related to brain injury
Ineffective airway clearance related to brain injury
Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? Intermittent mandatory ventilation (IMV) Assist control Synchronized intermittent mandatory ventilation (SIMV) Pressure support
Intermittent mandatory ventilation (IMV)
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? It results from inadequate delivery of nutrients and oxygen to the cells. It results from initial damage to the brain from the traumatic event. It refers to the permanent deficits seen after the rehabilitation process. It refers to the difficulties suffered by the client and family related to the changes in the client.
It results from inadequate delivery of nutrients and oxygen to the cells.
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the client will be promptly ordered the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? Lactated Ringer's Albumin Dextran 3% NaCl
Lactated Ringer's
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? Absence of infarcts or emboli Reduced stroke volume and cardiac output Absence of pulmonary and peripheral edema Maintenance of adequate mean arterial pressure
Maintenance of adequate mean arterial pressure
A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention? Insertion of an intracranial monitoring device Treatment with antihypertensives Making openings in the skull Administration of anticoagulant therapy
Making openings in the skull
The decision has been made to discharge a ventilator-dependent client home. The nurse is developing a teaching plan for this client and his family. What would be most important to include in this teaching plan? Administration of inhaled corticosteroids Assessment of neurologic status Turning and coughing Managing a power failure
Managing a power failure
The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? Central venous pressure of 6 mm Hg Mean arterial pressure of 70 mm Hg Urine output of 0.2 mL/kg/hr ScvO2 of 60%
Mean arterial pressure of 70 mm Hg
The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? Position the client the high Fowler position as tolerated. Administer osmotic diuretics as prescribed. Participate in interventions to increase cerebral perfusion pressure (CPP). Prepare the client for craniotomy.
Participate in interventions to increase cerebral perfusion pressure (CPP).
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. Which intervention may improve oxygenation and provide comfort for the client? Position the client in the prone position Force fluids for the next 24 hours Assist the client into a chair Administer small doses of pancuronium
Position the client in the prone position
Four hours after supratentorial surgery, the client is receiving intravenous (IV) fluid at 80 mL per hour, and the nurse is monitoring the client's neurologic status using the Glasgow Coma Scale. At 1015, the client has turned to the left side and is lying flat. At 1030, the nurse notes changes in the client's status (see chart.) What should the nurse do next? Note the changes, and continue to assess the client every 15 minutes. Notify the surgeon of these findings. Position the client supine with the head of the bed elevated at 30 degrees. Slow the rate of the intravenous (IV) fluid to 60 mL per hour.
Position the client supine with the head of the bed elevated at 30 degrees.
A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as Hypovolemic Progressive Neurogenic Compensatory
Progressive
A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? Lorazepam (Ativan) Midazolam (Versed) Phenobarbital Propofol (Diprivan)
Propofol (Diprivan)
The older adult client, who lives alone, has been admitted to the intensive care unit (ICU) following a stroke. She is now agitated and complaining about the noise. What will the nurse add to her care plan? Instruct the client in self-stimulation methods such as singing. Provide pet therapy. Provide a consistent, predictable pattern of stimulation. Offer frequent back rubs.
Provide a consistent, predictable pattern of stimulation.
A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse Elevates the head of the client's bed Raises the foot of the client's bed Turns the client to a side-lying position Places the client in a Trendelenburg position
Raises the foot of the client's bed
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? Bradycardia Tachycardia Increased blood pressure Reduced cardiac output
Reduced cardiac output
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock? Apply an antibiotic ointment to the client's mucous membranes, as ordered. Perform passive range-of-motion exercises unless contraindicated Initiate total parenteral nutrition (TPN) Remove invasive devices as soon as they are no longer needed
Remove invasive devices as soon as they are no longer needed
The nurse recognizes which symptom as a classic sign of cardiogenic shock? Restlessness and confusion Hyperactive bowel sounds High blood pressure Increased urinary output
Restlessness and confusion
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Septic Anaphylactic Neurogenic Cardiogenic
Septic
A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply. Headache Slurred speech Sleeps for short periods of time Vomiting Weakness on one side of the body
Slurred speech Vomiting Weakness on one side of the body
A client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for the cancer. What fact about lung cancer treatment should inform the nurse's response? The cells in small cell cancer of the lung are not large enough to visualize in surgery. Small cell lung cancer is self-limiting in many clients and surgery should be delayed. Clients with small cell lung cancer are not normally stable enough to survive surgery. Small cell cancer of the lung grows rapidly and metastasizes early and extensively.
Small cell cancer of the lung grows rapidly and metastasizes early and extensively.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? The CPP is high. The CPP is low. The CPP is within normal limits. The CPP reading is inaccurate.
The CPP is low.
The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs? The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity The release of catecholamines that creates an increase in metabolic rate and caloric requirements The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea
The release of catecholamines that creates an increase in metabolic rate and caloric requirements
Aneurysm
Weaker over time, looks like a blister, weaker and blooms out. finally burst and bleeds into brain
Unilateral neglect or inattention
a client's inability to recognize his or her physical impairment, especially on one side of the body
Intracerebal hemorrhage
bleeding into the brain as a result of a ruptured blood vessel within the brain
A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? PaCO2 <32 mm Hg compensatory respiratory alkalosis heart rate >20 bpm metabolic acidosis
compensatory respiratory alkalosis
A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing? decompensation stage compensation stage irreversible stage cardiogenic shock
decompensation stage
Dysarthria
difficulty forming words, slurred speech due to muscles in mouth are weak or partially paralyzed. nothing to do with brain (aphsia).
receptive aphasia (Wernicke's aphasia)
difficulty understanding language, difficulty comprehending what we are saying to them. they can speak but will be jumbled word salad, cant comprehend spoken words.
Agnosia
the inability to recognize familiar objects.
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Instruct the client to breathe into a paper bag. Administer oxygen by nasal cannula as ordered. Auscultate breath sounds bilaterally every 4 hours. Encourage the client to deep-breathe and cough every 2 hours.
Administer oxygen by nasal cannula as ordered.
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. Blood urea nitrogen (BUN) level Urine specific gravity Alkaline phosphatase level Creatinine level Serum albumin level
Creatinine level Blood urea nitrogen (BUN) level
The nurse is assessing an acutely ill patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock when: Fluid circulating in the blood vessels decreases. Cardiac output is increased. Blood pressure increases. Pulse is fast and bounding.
Fluid circulating in the blood vessels decreases.
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? Decreased heart rate Increased restlessness Increased blood pressure Decreased level of consciousness (LOC)
Increased restlessness
The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? Prepare to transfuse packed red blood cells. Prepare for interventions to increase the client's BP. Place the client in the Trendelenburg position. Prepare an ice bath to lower core body temperature.
Prepare for interventions to increase the client's BP.
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: Spatial-perceptual deficits. Left visual field deficit. Right-sided paralysis. Impulsive behavior.
Right-sided paralysis.
A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? The client should be approached on the side where visual perception is intact. Attention to the affected side should be minimized in order to decrease anxiety. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.
The client should be approached on the side where visual perception is intact.
A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? The drug should be discontinued immediately after blood pressure increases. The drug dose should be tapered down once vital signs improve. The client should have arterial blood gases drawn every 10 minutes during treatment. The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.
The drug dose should be tapered down once vital signs improve.
A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels? distributive cardiogenic hypovolemic organ failure
distributive
Ptosis
drooping
Acalculia
inability to perform mathematical calculations
Apraxia
inability to perform particular purposive actions, as a result of brain damage.
After a stroke, a client develops aphasia. The nurse expects to see which assessment finding? arm and leg weakness absence of the gag reflex difficulty swallowing inability to speak clearly
inability to speak clearly
Aphasia
inability to speak,
Global aphasia
inability to understand language or communicate orally.
Alexia
inability to understand written words
Agraphia
inability to write
A client admitted with possible ischemic stroke has been aphasic for 3 hours and has a blood pressure (BP) of 220/120 mm Hg. Which prescription by the health care provider should the nurse question? labetalol infusion to keep the BP lower than 120/80 mm Hg tissue plasminogen activator (t-PA) per protocol normal saline intravenously at 75 mL per hour bed elevated 30 degrees
labetalol infusion to keep the BP lower than 120/80 mm Hg
thrombotic stroke (ischemic)
most common, Clot that is Formed in the blood vessel
A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing? cardiogenic hypovolemic anaphylactic neurogenic
neurogenic
Contralateral sensory perception deficit
numbness, tingling, unusual sensations
hemiplegia
one-sided paralysis
Hemiparesis
one-sided weakness; often seen in those with CVA's.
At 4 AM the hemodynamic monitoring for a critically ill client in the intensive care unit indicates that the client's mean arterial pressure (MAP) is at the low end of the normal range; at 5 AM the client's MAP has fallen definitively below normal. The nurses should prioritize assessments for: dependent edema and decreased cognition. ischemic stroke and ischemic heart disease. organ damage and hypovolemic shock. orthostatic hypotension and cerebral aneurysm.
organ damage and hypovolemic shock.
Arterial blood gas analysis would reveal which value related to acute respiratory failure? PaO2 80 mm Hg pH 7.28 PaCO2 32 mm Hg pH 7.35
pH 7.28
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg
pH 7.28, PaO2 50 mm Hg
arteriovenous malformation- Hemorrhagic stroke
plaque buildup. thrombus forms,
uncontrolled Hypertension - Hemorrhagic stroke
risk for sudden rupture and bleeding into brain, very high BP or sudden raise(cocaine use)
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: pressure support ventilation (PSV). synchronized intermittent mandatory ventilation (SIMV). assist-control (AC) ventilation. continuous positive airway pressure (CPAP).
synchronized intermittent mandatory ventilation (SIMV).
expresive aphasia
trouble forming words that are understandable. they can comprehend but cant form words to respond back. may be able to respond in simple yes or no.
