CRITICAL CARE EXAM 3 UPDATED
a superficial partial-thickness (second degree) burn is characterized by?
Blistered skin with pink or moist base
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.)
Blood glucose 524 mg/dL, HCO3-10 mEq/L, pH 7.23
Which of the following assessment findings indicate that the patient with an acute cervical spinal cord injury is experiencing neurogenic shock?
Blood pressure of 84/56 and heartrate of 41
AIDS is defined by the presence of
CD4 count lower than 200/mm and the presence of an indicator condition. Is also the final stage of HIV
The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action?
CVP of 2 mm Hg
The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells, "my abdomen is killing me". When the nurse notes that the patient's abdomen is rigid should action should be taken next?
Call the healthcare provider (PCP) immediately.
Increased intracranial pressure
Can be caused from stroke or brain injury
A nurse is caring for a client who had an evacuation subdural hematoma. Which of the following actions should the nurse take first?
Check the oximeter
Neutropenia
Classified based in the pt's predicted risk for infection: mild (1000 to 1500), moderate (500 to 1000) and severe (< 500)
A nurse is interviewing a client with acute pancreatitis. Which of the following factors would the nurse anticipate finding in the patient's history?
Gallstones
The patient admitted with anemia caused by blood loss and thrombocytopenia has a platelet count of 22,000/microliter. The patient is scheduled for a transfusion of red blood cells (RBCs) and a transfusion of platelets. The nurse should take what action?
Give the platelets before the RBCs.
What strategies are appropriate for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE) in an at-risk patient? (Select all that apply.)
Graduated compression stockings. Heparin or low-molecular weight heparin. Sequential compression devices.
The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned about acquired immune deficiency syndrome (AIDS). The patient's blood work shows the presence of HIV antibodies. The nurse should explain that?
HIV infection and AIDS are considered chronic diseases.
Which of the following activities may help decrease increased cranial pressure?
Head elevation to 30 degrees
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as priority?
Hematolysis (massive bleeding, bleeding out)
What diagnostic procedure is required to make a definitive diagnosis of pulmonary embolism?
High resolution multidetector CT angiogram.
What differences would you expect to see in patients experiencing hyperosmolar hyperglycemic syndrome rather than diabetic ketoacidosis?
Higher serum glucose, higher osmolality, and no ketosis
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?
ICP is high; CPP is normal.
The patient admitted with neutropenia, should have regular assessments focus on what?
Identifying signs of systemic infection.
The nurse caring for a patient with an acute ischemic stroke anticipates?
Identifying the precise time of stroke symptom onset when possible
Trends in nutritional management of the patient with pancreatitis are changing regarding what aspect of care?
Immediate oral feeding in patients with mild pancreatitis may help recovery.
The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should provide what answer?
"Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain."
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?
"This injection is being given to prevent blood clots from forming."
Select three findings in a client's medical record that will increase their risk for peptic ulcer disease?
(Go over indications and causes) • Smoking, alcohol use, spicy foods, frequent NSAIDS use, h-pylori, un-treated stress,
Following an assessment of the blood glucose via fingerstick, a value of 54 mg/dl was obtained on the critical care patient. What is the priority intervention using the 15/15 rule for glucose management?
1 tablespoon (15 grams) of sugar and repeat fingerstick in 15 minutes to determine effectiveness of intervention
Normal ICP is
10-15. 20 over 5 mins is life threatening.
The patient admitted with acute pancreatitis is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient has what morality rate?
15%
Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count at what level?
1500 cells/microliter or higher.
Which statement is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?
PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE.
Why is pain control a nursing priority in patients with acute pancreatitis?
Pain increases pancreatic secretions.
GCS scores range from
3 (deep coma) to 15 (normal functioning)
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?
90 (subtract MAP from ICP)
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?
Assist the patient to the floor and provide soft head support.
A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered for a patient who presented to the emergency department experiencing diabetic ketoacidosis. What is the targeted blood glucose value after the first hour of therapy?
A decrease of 50 to 75 mg/dL compared with admitting values
What is the most common cause of a pulmonary embolus?
A deep vein thrombosis from lower extremities.
What is a cause of a secondary immunodeficiency that involves the loss of a previously functional immune defense system? (Select all that apply.)
AIDS. aging. nutritional deficiencies. immunosuppressive therapies.
The nurse caring for a patient with acute pancreatitis implements what intervention in order to provide adequate pain control?
Administers pain medication on a routine schedule.
What is responsible for maintaining the body's oncotic pressure?
Albumin
What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.)
Altered sleep/rest patterns. Eating disorder. High levels of stress. Lack of financial resources.
An elderly patient who is being admitted for anemia of unknown cause has been on multiple medications at home for various ailments. In assessing the patient's medication list, the nurse notes which medications that may alter hemostasis? (Select all that apply.)
Aminoglycosides. Antiplatelet agents. Cephalosporins. Sulfonamides.
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?
An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza
Which leads to inadequate oxygenation of tissues?
Anemia
Sudden, severe, pounding headaches, elevated uncontrolled bp, bradycardia, nasal congestion, blurred vision, profuse diaphoresis above the level of injury, pallor chills, and pilomotor erection below the level of injury
Assess for a kinked urinary catheter and assess for bowel impaction.
The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly reports experiencing abdominal pain and chills. The patient's temperature is elevated. The nurse should take what action?
Assess peritoneal dialysate return.
The nurse is assessing the patient admitted diagnosed with pancreatitis. In doing so, the nurse takes what action?
Assesses symptoms that could indicate involvement of the stomach.
A nurse is planning care for a client that has cirrhosis. Which of the following interventions should the nurse include in the plan of care?
Decrease fluid intake
A patient diagnosed with type 1 diabetes 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 what possible complication?
Diabetic ketoacidosis
The patient getting hemodialysis for the second time reports a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of what possible complication?
Dialysis disequilibrium syndrome
A nurse is caring for a client who has burns to his face ears and eyelids. The nurse should identify which of the following as priority finding?
Difficulty swallowing
A nurse is assessing a client with HYPERthyroidism. The nurse should expect the client to report the following manifestations.
Frequent mood changes
HHS (Hyperosmolar hyperglycemic syndrome)
Dx: serum glucose concentration is significantly more elevated may exceed 3000, plasma osmolarity is higher, acidosis is not present, ketosis is usually absent
A nurse is providing care for a patient who has developed Kaposi's sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?
Endothelial cells lining small blood vessels
The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower than normal ratio may indicate acquired immunodeficiency syndrome (AIDS). What is the role of T4 cells?
Enhances humoral immune response.
What medications are prescribed to patients recently diagnosed with peptic ulcer disease (PUD) from Helicobacter pylori?
Esomeprazole, amoxicillin, and clarithromycin.
Early clinical signs of liver disease include all of the following except?
Esophageal varices
The patient is admitted with acute pancreatitis. The nurse should be prepared to take what action?
Evaluate C-reactive protein as a gauge of severity.
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?
Fatigue
Which nursing diagnosis is a high-priority for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?
Fluid volume deficit
What is the treatment for an acute exacerbation of asthma?
Inhaled bronchodilators and intravenous corticosteroids
The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for what intervention?
Insertion of a percutaneous catheter at the bedside.
What is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants?
Insertion of a vena cava filter.
The patient receiving hemodialysis 3 days a week is 74 inches tall and weighs 100 kg. In planning the care for this patient, the nurse provides what nutritional recommendation?
Intaking 2500 to 3500 kcal diet per day
How is peritoneal dialysis different from hemodialysis?
It uses the patient's own semipermeable membrane (peritoneal membrane).
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for escharotomy. The clients spouse asks the nurse what the procedure entails. Which of the following statements is appropriate?
Large incisions will be made in eschar to improve circulation.
What are the nursing priorities for the management of acute pancreatitis? (Select all that apply.)
Managing respiratory dysfunction. Assessing and maintaining electrolyte balance. Utilizing supportive therapies aimed at decreasing gastrin release.
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 order should the nurse institute first?
Mannitol 1 g intravenous
The nurse assessing a patient being admitted for anemia observes no overt signs of bleeding. The nurse understands what fact about the clinical presentation of anemia?
Many patients have bleeding that is not obvious.
Which of the following statements is true regarding thyroid storm?
Marked tachycardia may be observed.
Autonomic dysreflexia
Medical Emergency: Can result in stroke, seizures, or other compilations.
The nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?
Metformin
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which intervention?
Mobility
A nurse is caring for a client who has a full thickness burn over 75% of his body. The nurse should use which of the following methods to monitor his cardiovascular system?
Monitor pulmonary artery pressure
The nurse assesses a patient with a skull fracture and notes 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?
Monitor the patient's airway patency.
The patient admitted with pancreatitis presents with severe ascites. In caring for this patient, the nurse should take what action?
Monitor the patient's blood pressure and evaluate for signs of dehydration.
Possible treatments for acute respiratory in the patient with COPD include:
Noninvasive ventilation. bronchodilators. corticosteroids.
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?
Notify the primary care provider immediately.
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action?
Place a nasal drip pad under the nose.
A patient diagnosed with severe pancreatitis is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and should have taken what action?
Places the patient on seizure precautions.
A patient is admitted to the critical care unit with a diagnosis of possible meningitis. Actions the nurse anticipates include all of the following except:
Placing the patient on contact precautions
A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect to be decreased?
Platelets
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?
Potassium
The patient is diagnosed with hepatitis. In caring for this patient, the nurse should be prepared to take what action?
Provide rest, nutrition, and antiemetics as needed.
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.)
Recording ICP as a "mean" value. Zero referencing the transducer system.
When collecting data from a client with kaposi's sarcoma (KS) the nurse should expect to observe which of the following?
Reddish-purple skin lesions
Autonomic dysreflexia
Sudden, severe, pounding headaches, elevated uncontrolled bp, bradycardia, nasal congestion, blurred vision, profuse diaphoresis above the level of injury, pallor chills, and pilomotor erection below the level of injury
The nurse discharging a patient diagnosed with asthma instructs the patient to prevent exacerbation by taking what action?
Taking all asthma medications as prescribed.
What is an advantage of peritoneal dialysis?
The danger of hemorrhage is minimal.
When the patient's hematological and immunological systems are compromised, it is not uncommon to require transfusions of several different types of blood products. What patient condition would warrant the administration of platelets as the first consideration?
Thrombocytopenia
When the patients hematological and immunological systems are compromised, it is not uncommon to require transfusions of several different types of blood products. What patient condition would warrant the administration of platelets as the first consideration?
Thrombocytopenia
A nurse is teaching a client with acute kidney injury about ((oliguria phase???)). Which of the following information should the nurse include in the teaching?
Urine output of less than 400 ml in 24 hours
Which of the following statements is true about the medical management of diabetic ketoacidosis?
Volume replacement and insulin infusion often correct the acidosis.
In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started?
When the blood glucose reaches 250 mg/dL
What causes anemia? (Select all that apply.)
blood loss. impaired production of red blood cells. increased destruction of red blood cells.
Dialysis disequilibrium syndrome
caused by the rapid removal of urea during hemodialysis; CNS disorder Rx factors: elevated BUN above 175 Manifestations: headache, nausea, vomiting, decreased LOC, seizures, restlessness; when severe, patient progress to confusion, seizures, coma, death
A GCS of 8 or less is
consistent with coma.
neurogenic shock is characterized by
hypotension, bradycardia, and hypothermia
When caring for a patient with HIV, the nurse should?
monitor the patient's medication regimen.
Which laboratory values would be more common in patients with diabetic ketoacidosis?
pH 7.24
lower tidal volumes are an evidence-based method for
preventing ventilatior induced lung injury
Which acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?
respiratory acidosis