Endocrine, GI/GU, Neurology
Your patient is 46-year-old female who suffered a head injury in a motor vehicle accident. Her blood pressure is 130/60 and her intercranial pressure is 14. Calculate your patients cerebral perfusion pressure (CPP)
CPP is 69
A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action with the nurse take first? a. Insert a urinary retention catheter b. Place the patient on a cardiac monitor c. Give Kayexalate d. Administer epoetin alfa
b. Place the patient on a cardiac monitor
Which topic is most important for the nurse to include and teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis? a. Using vitamin B supplements b. Maintaining good nutrition c. Taking lactulose d. Avoiding all alcohol use
d. Avoiding all alcohol use
Admission vital signs for a patient who has a brain injury are BP of 128/64, pulse of 110, 24 respirations/min. Which set of vital signs if taken 1 hour later will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30
A Blood pressure 156/60, pulse 55, respirations 12
Which information would the nurse explain to the patient who has a T2 spinal cord transection injury? A. Tachycardia is common with this type of injury B. Total loss of respiratory function may occur C. Function of both arms would be preserved D. Use of the shoulders will be limited
C. Function of both arms would be preserved
A patient is hospitalized with AKI. Which information will be most useful to the nurse in evaluating improvement in kidney function? A. BUN level B. Creatinine level C. GFR D. Urine volume
C. GFR
The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires the most rapid action from the nurse? A. The apical pulse is slightly irregular B. The patient reports a headache C. The patient is more difficult to arouse D. The BP increases to 140/62
C. The patient is more difficult to arouse
The nurse recognizes that which patient is most likely to develop CKD and will benefit from education about prevention? A. A 61 year old Native American with diabetes B. A 28 year old African American with a UTI C. A 50 year old White patient with HTN D. A 40 year old Hispanic patient with cardiovascular disease
A. A 61 year old Native American with diabetes
To prevent autonomic dysreflexia, which nursing action would the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level A. Assist to plan a prescribed bowel program B. Use quad coughing to strengthen cough efforts C. Support selection of a high protein diet D. Discuss options for sexuality and fertility
A. Assist to plan a prescribed bowel program
A client with a head injury has a Ct scan that shows a subdural hematoma. How would the nurse interpret this? A. Blood between the dura mater and the arachnoid mater B. Blood between the dura and the skull C. Blood within the brain tissue D. Blood in the subarachnoid space
A. Blood between the dura mater and the arachnoid mater
For which clinical indicator associated with a complication of portal hypertension would the nurse assess in the client? A. Hemorrhage from esophageal varices B. Intestinal obstruction C. Liver abscess D. Perforation of the duodenum
A. Hemorrhage from esophageal varices
Which assessment finding would the nurse expect when a patient with AKI has an arterial blood pH of 7.30? A. Rapid, deep respirations B. Bounding peripheral pulses C. Persistent skin tenting D. Hot, flushed face and neck
A. Rapid, deep respirations
The nurse is caring for a patient with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? A. The patients hands flap back and forth when the arms are extended B. The patient's abdominal skin has multiple spider shaped blood vessels C. The patient reports right upper quadrant pain with palpation The patient has ascites and a 2kg weight grain from the previous day
A. The patients hands flap back and forth when the arms are extended
A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to verbal commands or painful stimulus. How would the nurse record the patient's GCS? A. 15 B. 11 C. 13 D. 9
B 11
A patient with a history of T2 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse "I have a pounding headache and I feel sick to my stomach." Which action would the nurse take first? A. Check for fecal impaction B. Assess the BP C. Notify the HCP D. Give the prescribed antiemetic
B. Assess the BP
Which risk is the nurse's priority concern for a patient with delirium who becomes severely agitated? A. Thiamine deficiency B. Falls C. Disorientation D. Hypoactive motor function
B. Falls
The nurse is admitting a patient who has a neck fracture at the C6 level to the ICU. Which findings on the nursing assessment would indicate neurogenic shock? A. Involuntary and spastic movement B. Hypotension and warm extremities C. Lack of sensation or movement below the injury D. Hyperactive reflexes below the injury
B. Hypotension and warm extremities
Which assessment information will be the most important for the nurse to report to the health care provider about a patient who has acute cholecystitis? A. The patient has increased pain after eating B. The patient's stools are tan colored C. The patient reports chronic heartburn D. The patient's urine is bright yellow
B. The patient's stools are tan colored
Which hospitalized patient will the nurse assign to the room closest to the nurses station? A. Patient with vascular dementia who takes medications for depression B. Patient with Alzheimer disease who has long-term memory deficit C. Patient with dementia who has an abnormal Mini-Mental-State Examination D. Patient with new onset confusion, restlessness and irritability after surgery
D. Patient with new onset confusion, restlessness and irritability after surgery
A patient who has possible cerebral edema has a serum sodium level of 116 and a decreasing level of consciousness. The patient is now reporting headache. Which prescribed intervention would the nurse implement first? a. Administer IV hypertonic solution b. Administer acetaminophen (Tylenol) 650mg c. Send the patient for CT d. Draw blood for arterial blood gases (ABGs)
a. Administer IV hypertonic solution
During routine hemodialysis, a patient reports nausea and dizziness. Which action would the nurse take first? a. Check the blood pressure b. Slow down the rate of dialysis c. Review the hematocrit level d. Give prescribed PRN antiemetic drugs
a. Check the blood pressure
A patient who has diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse explain for meal time coverage? a. Detemir (Levemir) b. Lispro (Humalog) c. Glargine (Lantus) d. NPH (Humulin N)
b. Lispro (Humalog)
Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-year-old receiving IV antibiotics for meningococcal meningitis b. A 25-year-old admitted with a skull fracture and craniotomy the previous day c. A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy d. A 35-year-old with ICP monitoring after a head injury last week
a. A 45-year-old receiving IV antibiotics for meningococcal meningitis
A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM
a. 10:00 AM
After change of shift report which patient would the nurse assess first? a. 23-year-old patient with T1DM, who has glucose of 40 b. 40-year-old patient who is pregnant and oral glucose tolerance test is 202 c. 50-year-old patient who uses exenatide and is reporting acute abdominal pain d. A 19-year-old patient with T1DM who has a hemoglobin A1c of 12%.
a. 23-year-old patient with T1DM, who has glucose of 40
Which Glascow coma Scale score would the nurse assign an unconscious patient who opens the eyes in response to pain but who does not respond to any other stimulus, moans to any verbal communication, and demonstrates flexion withdrawal? a. 8 b. 6 c. 4 d. 10
a. 8
Which assessment finding would the nurse need to report most quickly to the healthcare provider regarding a patient who has pancreatitis? a. Upper abdominal tenderness and guarding b. Muscle twitching, and finger numbness c. Nausea and vomiting d. Hypotonic bowel sounds
b. Muscle twitching, and finger numbness
A 20-year-old is admitted with a head injury after a collision while playing sports. After noting that the patient has developed, clear, nasal drainage, which action with the nurse take? a. Check the drainage for glucose content b. Teach the patient that rhinorrhea is expected after a head injury c. Have the patient gently blow the nose d. Obtain a specimen of the fluid to send for culture and sensitivity
a. Check the drainage for glucose content.
Which objective information would the nurse record when assessing a patient with a head injury? SATA. a. Cranial nerve deficits b. Mechanism of injury c. Projectile vomiting d. Headache e. Past health history f. Battle sign
a. Cranial nerve deficits c. Projectile vomiting f. Battle sign
After endotracheal suctioning the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17. Which action would the nurse take first? a. Ensure that the patient's neck is in neutral position b. Notify the healthcare provider about the change in pressure c. Document the increase intracranial pressure d. Increase the rate of the prescribe propofol infusion
a. Ensure that the patient's neck is in neutral position
The nurse has administered prescribed IV Manitau to an unconscious patient. Which parameter with the nurse monitor to determine the medication effectiveness? a. ICP b. Hemoglobin and hematocrit c. Oxygen saturation d. Blood pressure
a. ICP
A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees b. Encourage coughing and deep breathing c. Position the patient with knees and hips flexed d. Cluster nursing intervention to provide rest periods
a. Keep the head of the bed elevated to 30 degrees
A 68-year-old male patient is admitted to the emergency department for sudden onset of severe left upper quadrant abdominal pain with nausea and vomiting. His abdomen is distended, with decreased bowel sounds in all quadrants. He tells the nurse that he was diagnosed with gallstones a year ago and was told to have surgery to remove his gallbladder, but he was too busy with work to take time for surgery. He has a history of type 2 diabetes mellitus. Vital signs: Temp 99 F, Pulse 110, respirations 26, and blood pressure 178/98. He is diagnosed with probable acute pancreatitis. Which of the following is indicated, contraindicated, or nonessential? a. Prepare for oral glucose testing with 75g or glucose b. Educate the patient about the need for fluid restrictions c. Give PO foods as tolerated d. Monitor the patient for respiratory distress e. Administer an antispasmodic such as atropine to reduce GI pain f. Monitor serum
a. Nonessential b. Indicated c. Indicated d. Indicated e. Indicated f. Indicated g. Indicated
A 27-year-old patient admitted with DKA has a serum glucose level of 732 and a serum potassium level of 3.1. Which action prescribed by the healthcare provider with the nurse implement first? a. Place the patient on a cardiac monitor b. Start an insulin infusion at 0.1 units/kg/hr c. Administer IV potassium supplements d. Ask the patient about home insulin doses
a. Placed the patient on a cardiac monitor
A patient who has had a C7 spinal cord injury one week ago, has a week off effort and crackles. Which initial intervention, would the nurse perform? a. Push upward on the epigastric area as a patient coughs b. Notify the patient's healthcare provider c. Suction the patient nasopharynx d. Encourage and incentives spirometry every two hours during the day
a. Push upward on the epigastric area as the patient coughs.
The nurse is caring for a patient who is admitted the previous day with a basilar fracture after a motor vehicle crash. Which assessment finding indicates a possible complication, that should be reported to the healthcare provider? a. Temperature 101.4 F b. Large contusion behind left ear c. Report of severe headache d. Bilateral periorbital ecchymosis
a. Temperature 101.4 F
After reviewing the health record for a patient who has multiple risk factors for Alzheimer's disease (AD), which would be most important for the nurse to discuss with the patient? Pt. history: age 58, history of closed head injury, mother died at age 68 of AD. Habits: smokes, 15 cigarettes, daily, one to two glasses of wine weekly, rides, a bike to and from work. Lab results: total cholesterol 220, HDL 80, LDL 103. a. Tobacco use b. Family history c. Head injury history d. Cholesterol level
a. Tobacco use
Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH) ? a. "I should weigh myself daily and report, sudden, weight, loss, or gain " b. "I need to shop for foods, low and sodium and avoid adding salt to food. " c. "I should eat food and potassium, because diuretics caused potassium loss " d. "I need to limit my fluid intake to no more than 1 quart of liquids a day "
b. "I need to shop for foods low in sodium and avoid adding salt to food."
Which information will a nurse teach a patient who has been newly diagnosed with Graves' disease? a. Surgery will eventually be required to remove the thyroid gland b. Anti-thyroid medication may take months for full effect c. Exercise is contraindicated to avoid increasing metabolic rate d. Restriction of iodine intake will help reduce thyroid activity
b. Anti-thyroid medication may take months for full effect.
Which physical assessment finding with the nurse document on a client who is experiencing Cushing triad? SATA a. Tachycardia b. Bradycardia c. Diastolic hypertension d. Irregular respirations e. Widening pulse pressure f. Systolic hypertension
b. Bradycardia d. Irregular respirations e. Widening pulse pressure f. Systolic hypertension
Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication
b. Having the patients family member administer the medication
A patient's blood pressure is 120/60 and the intracranial pressure is 24. After calculating the patient's cerebral perfusion pressure (CPP), which interpretation would the nurse apply to the results? a. Adequate auto regulation of blood flow b. Impaired blood flow to the brain c. Normal ICP d. High blood flow to the brain
b. Impaired blood flow to the brain
The nurse is admitting a patient with a basal school fracture. The nurse notes ecchymosis around both eyes and clear drainage from the patient's nose. Which admission order with the nurse question? a. Apply cold packs, intermittently to face b. Insert nasogastric tube to low suction c. Turn patient side to side every two hours d. Keep the head of the bed elevated
b. Insert nasogastric tube to low suction
Which menu choice by the patient who is receiving hemodialysis indicates that the nurses teachings have been successful? a. Cheese sandwich, tomato, soup, and cranberry juice b. Poached, eggs, whole wheat toast, and apple juice c. Oatmeal with cream, half of a banana, and herbal tea d. Split-pea soup, English muffin, nonfat milk.
b. Poached, eggs, whole wheat toast, and apple juice.
A patient with Cushing syndrome is admitted for an adrenal ectomy. Which information would likely help the patient cope with a disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are common and patient with Cushing syndrome b. Remind the patient that most of the physical changes caused by Cushing syndrome, will resolve after surgery c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance d. Disc
b. Remind the patient that most of the physical changes caused by Cushing syndrome, will resolve after surgery.
A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.
b. Report the BP and ICP to the healthcare provider.
Which assessment data for a patient who has Guillain-Barré syndrome requires the most immediate action? a. The patient's blood pressure is 150/82 b. The patient is continuously drooling saliva c. The patient sacral area skin is reddened d. The patient reports severe pain in the feet
b. The patient is continuously drooling saliva
A patient has been hospitalized for four days with acute kidney injury caused by dehydration. Which information would be most important for the nurse to report to the healthcare provider? a. The blood urea nitrogen (BUN) level is 67 b. Urine output over an eight hour period is 2500mL c. The glomerular filtration rate is less than 30 mL/min d. The creatinine level is 3.0
b. You're an output over an eight hour is 2500mL
The patient received regular insulin eight units subcutaneously at 0900. During which time range would the nurse plan to monitor the patient for signs of hypoglycemia? a. 1300-1500 b. 1200-1300 c. 1100-1400 d. 1000-1100
c. 1100-1400
Which initial action would the nurse take for a patient with moderate dementia, who develops increased restlessness and agitation? a. Administer a PRN dose of lorazepam (Ativan) b. Assign assistive personnel to stay in the patient's room c. Assess for factors that might be causing discomfort d. Re-orient the patient to time place in person
c. Assess for factors that might be causing discomfort
Which action would the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C-5 spinal cord injury? a. Application of pneumatic compression devices to legs b. Cardiac monitoring for bradycardia c. Assessment of respiratory rate and effort d. Administration of low-molecular-weight heparin
c. Assessment of respiratory rate and effort
Which action would the nurse in the emergency department take first for a patient who arrives vomiting blood due to ruptured esophageal varies? a. Draw blood for coagulation studies b. Place the patient in supine position c. Check blood pressure and heart rate d. Insert a large gauge IV catheter
c. Check blood pressure and heart rate.
A patient with acute kidney injury has longer QRS intervals on the ECG and were noted on the previous shift. Which action would the nurse take first? a. Document the QRS interval measurement b. Review the chart for the patient's current creatinine level c. Check the patient's most recent potassium level d. Notify the patient's healthcare provider
c. Check the patient's most recent potassium level
When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? a. The patient exhibits nuchal rigidity b. The patient has a positive Kernig's sign c. The patient's blood pressure is 88/42 d. The patient's temperature is 101 F
c. The patient's blood pressure is 88/42
The nurse is assessing a 22-year-old patient experiencing the onset of type 2 diabetes. Which finding would the nurse anticipate? a. Anorexia b. Craving sugary drinks c. Weight loss d. Dark colored urine
c. Weight loss
The nurse admits a patient to the hospital and Addisonian crisis. Which patient statement supports the need to plan additional teaching? a. "I always double my dose of hydrocortisone on the days that I go for a long run. " b. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon. " c. "I frequently eat at restaurants and food has a lot of added salt " d. "I had the flu earlier this week so I couldn't take the hydrocortisone "
d. " I had the flu earlier this week so I couldn't take the hydrocortisone."
After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c. A 40-year-old patient who lost consciousness for a few seconds after a fall d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium, which intervention with nurse implement Initially? a. Ask the healthcare provider to prescribe an antipsychotic drug b. Instruct family members to remain with the patient and prevent injury c. Secure the patient in bed using a soft chest restraint d. Assign assistive personnel to stay with a patient and re-orient the patient
d. A sin assistive personnel to stay with a patient and re-orient the patient.
Which physiologic result would the nurse associate with a patient reporting a headache, who has disturbed consciousness, and imaging studies, indicate cerebral edema in white matter? a. Something caused abnormal accumulation of CSF in the brain b. An intact blood brain barrier is present c. A decreased oxygen supply to the brain exists d. An increase in the cerebral extracellular fluid occurred
d. An increase in the cerebral extracellular fluid volume occurred
A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. Which topic was the nurse plan to teach the patient? a. Including whole grains in the diet to prevent constipation b. Bisphosphonates to reduce bone demineralization. c. Increasing fluid intake to decrease risk for nephrolithiasis d. Calcium supplements to normalize serum calcium levels
d. Calcium supplements to normalize serum calcium levels
A client is diagnosed with Cushing syndrome. The nurse would monitor the client for which cardiovascular complication? a. Chest pain b. Atrial fibrillation c. Tachycardia d. Hypertension
d. Hypertension
Which intervention would the nurse implement during a peritoneal fluid exchange of a client with stage renal disease receiving peritoneal dialysis? a. Remove the cannula at the end of the procedure and apply a dry sterile dressing b. Allow the patient to urinate the remaining solution c. Maintain the client and the supine physician during the entire procedure d. Position the client from side to side if fluid is not draining adequately
d. Position the client from side to side if the fluid is not draining adequately
Which client laboratory result is consistent with a diagnosis of Cushing syndrome? a. Salivary cortisol level: 1 b. Salivary cortisol level: 1.2 c. Salivary cortisol level: 1.9 d. Salivary cortisol level: 2.3
d. Salivary cortisol level: 2.3
A patient's blood glucose level before breakfast is 324. The nurse reviews the electronic medical record and notes that the patient receives a high dose of insulin each evening at bedtime and the nurse suspects that the patients hyperglycemia is most likely due to which problem with insulin therapy? a. Lipodystrophy b. Allergic reaction. c. Dawn phenomenon. d. Samogyi effect.
d. Samogyi effect
A patient hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information that the patient is experiencing delirium rather than dementia. a. The patient is oriented to person but disoriented to place and time b. The patient has a history of increasing confusion over several years c. The patient's speech is fragmented and incoherent d. The patient was oriented and alert when admitted
d. The patient was oriented and alert when admitted.
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for ICP monitoring. Which statement by the nurse would be the best initial response? a. The ventric. monitoring system helps check for changes in CPP b. The monitor has many benefits, including ability to drain CSF c. This is a complex type of monitoring and is managed by skilled staff d. The system measures pressure to determine blood flow to the brain is good.
d. The system measures pressure to determine whether blood flow to the brain is adequate.
