Exam 1 (Spring 2025)

The nurse recognizes that this principle guides individual health care decisions: A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

A. Autonomy

Which of the following is a component of a healthy work environment? A. Collaboration B. Use of many agency nurses C. Crew-resource training D. Evidence-based practice

A. Collaboration

A patient admitted to the emergency department 24 hours ago with reports of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate? A. Dysrhythmias B. Unstable angina C. Cardiac tamponade D. Sudden cardiac death

A. Dysrhythmias

Which antilipemic medications should the nurse question for a patient who has cirrhosis of the liver? (Select all that apply.) A. Niacin B. Cholestyramine C. Ezetimibe (Zetia) D. Gemfibrozil (Lopid) E. Atorvastatin (Lipitor)

A. Niacin C. Ezetimibe (Zetia) D. Gemfibrozil (Lopid) E. Atorvastatin (Lipitor)

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administering? A. Oxygen, nitroglycerin, aspirin, and morphine B. Aspirin, nitroprusside, dopamine, and oxygen C. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine D. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

A. Oxygen, nitroglycerin, aspirin, and morphine

A patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which patient assessment would determine the effectiveness of the medication? A. Presence of chest pain B. Blood in the urine or stool C. Tachycardia with hypotension D. Decreased level of consciousness

A. Presence of chest pain

A patient returns to the unit after a cardiac catheterization. Which nursing care would the registered nurse delegate to the unlicensed assistant personnel (UAP)? A. Take vital signs and report any abnormal values. B. Check for bleeding at the catheter insertion site. C. Prepare discharge teaching related to complications. D. Monitor the electrocardiogram for S-T segment changes.

A. Take vital signs and report any abnormal values.

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. BP 154/68, pulse 56, respirations 12 b. BP 134/72, pulse 90, respirations 32 c. BP 148/78, pulse 112, respirations 28 d. BP 110/70, pulse 120, respirations 30

A: BP 154/68, pulse 56, respirations 12 Rationale: Systolic HTN with widening pulse pressure, bradycardia, and respiratory changes represent Cushings triad. These findings indicate that the intracranial pressure has increased, and brain herniations may be imminent unless immediate action is taken to reduce ICP.

A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Flushing and pruritus after taking the medications

A: Generalized muscle aches and pains Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.

When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

A: Give the scheduled aspirin and lipid-lowering medication. Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness

A: Ineffective coping related to anxiety The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity.

A 31-year-old woman who has MS asks the nurse about risks associated with pregnancy. which response by the nurse is accurate? a. MS symptoms may be worse after the pregnancy b. women with MS frequently have premature labor c. MS is associated with an increased risk for congenital defects d. symptoms of MS are likely to become worse during pregnancy

A: MS symptoms may be worse after the pregnancy Rationale: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms may improve during pregnancy.

Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. An increase in troponin levels from baseline c. A large bruise at the patient's IV insertion site d. A decrease in ST-segment elevation on the electrocardiogram

A: No change in the patient's chest pain Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac markers into the circulation as the blocked vessel is opened.

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient's care? a. Sildenafil (Viagra) b. Furosemide (Lasix) c. Captopril (Capoten) d. Warfarin (Coumadin)

A: Sildenafil (Viagra) The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

A: What do you think caused your chest pain?" When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

Which patient is most appropriate for the intense care unit charge nurse to assign to a 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 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 Rationale: An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis

A male patient who has possible cerebral edema has a serum sodium level fo 116 mEq/L and a decreasing level of consciousness. He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. administer IV 5% hypertonic saline b. draw blood for arterial blood gas c. send patient for CT d. administer acetaminophen 650 mg PO

A: administer IV 5% hypertonic saline Rationale: The patients low sodium indicates that hyponatremia may be causing the cerebral edema. Acetaminophen will have minimal effect on the headache because it is caused by cerebral Eem and increased intracranial pressure.

The HCP is considering the use of sumatriptan for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the HCP? a. the patient drinks 1 to 2 cups of coffee daily b. give the scheduled dose of divalproex c. document the timing and description of the seizure d. notify the patients HCP about the seizure

A: assess the patient for a possible head injury Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication.

The nurse observes a patient ambulating in the hospital hall when the patients arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible head injury b. give the scheduled dose of divalproex c. document the timing and description of the seizure d. notify the patients health care provider about the seizure

A: assess the patient for a possible head injury Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication.

A 64-year-old patient who has amyotrophic lateral sclerosis is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. assist with active ROM b. observe for agitation and paranoia c. give muscle relaxants as needed to reduce spams d. use simple words and phrases to explain procedures

A: assist with active ROM Rationale: ALS causes progressive muscle weakness, but assisting the patient to perform ROM will help maintain strength as long as possible.

A 68-year-old male patient is brought to the ED by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. check oxygen saturation b. assess pupil reaction to light c. verify Glasgow Coma Scale score d. palpate the head for hematoma or bony irregularities

A: check oxygen saturtion Rationale: Airway potency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

A 46-year-old patient tells the nurse about using acetaminophen several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. discuss the need to stop taking the acetaminophen b. suggest the use of biofeedback for headache control c. describe the use of botulism toxin for headaches d. teach the patient about MRI

A: discuss the need to stop taking the acetaminophen Rationale: The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication.

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. While nursing action will be included in the plan of care? a. encourage family members to remain at the bedside b. apply soft restraints to protect the patient from injury c. keep the room well-lighted to improve patient orientation d. minimize contact with the patient to decrease sensory input

A: encourage family members to remain at the bedside Rationale: Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. encourage the use of effective insect repellents during mosquito season b. remind patients that most cases of viral encephalitis can be cared for at home c. teach about the importance of prophylactic antibiotics after exposure to encephalitis d. arrange for screening of school-age children for West Nile virus during the school year

A: encourage the use of effective insect repellents during mosquito season Rationale: Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an ICU during the initial stages.

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure? a. focal b. atonic c. absence d. myoclonic

A: focal Rationale: The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and falls to the ground. Myoclonic seizures are characterizes by a sudden jerk of the body or extremities.

A patient has been taking phenytoin for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. inspect the oral mucosa b. listen to the lung sounds c. auscultate the bowel tones d. check pupil reaction to light

A: inspect the oral mucosa Rationale: Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.

After change-of-shift report, which patient should the nurse assess first? a. patient with myasthenia gravis who is reporting increased muscle weakness b. patient with a bilateral headache described as like a band around my head c. patient with seizures who is scheduled to receive a dose of phenytoin d. patient with Parkinson's disease who has developed cogwheel rigidity of the arms

A: patient with myasthenia gravis who is reporting increased muscle weakness Rationale: Because increased muscle weakness may indicate the onset of a myasthenia crisis, the nurse should assess this patient first. The other options do no require immediate attention.

The nurse advises a patient with myasthenia graves to a. perform physical demanding activities early in the day b. anticipate the need for weekly plasmapheresis treatments c. do frequent weight-bearing exercise to prevent muscle atrophy d. protect the extremities from injury due to poor sensory perception

A: perform physically demanding activities early in the day Rationale: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroids must be avoided.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing post concussion syndrome? a. short-term memory b. muscle coordination c. Glasgow Coma Scale d. pupil reaction to light

A: short-term memory Rationale: Decreased short-term memory is one indication of post concussion syndrome.

A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. start the ordered PRN oxygen at 6L/min. b. put a moist hot pack on the patients neck c. give the ordered PRN acetaminophen d. notify the patients HCP immediately

A: start the ordered PRN oxygen at 6 L/min. Rationale: Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider.

When admitting a 42-year-old patient a possible brain injury after a car accident to the ED, the nurse obtains the following information. Which finding is most important to report to the HCP? a. the patients take Warfarin (Coumadin) daily b. the patients BP is 162/94 mmHg c. the patient is unable to remember the accident d. the patient complains of a severe dull headache

A: the patient takes Warfarin (Coumadin) daily Rationale: The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported.

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

A: when cardiac rehabilitation will begin. Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction (MI).

1. Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma may exist include which of the following? (Select all that apply.) a. Family members are confused about what is happening to the patient. b. Family members are in conflict as to the best treatment options. They disagree with one another and cannot come to consensus. c. The family asks that the patient not be told of treatment plans. d. The patient's condition has changed dramatically for the worse and is not responding to conventional treatment. e. The physician is considering the use of a medication that is not approved to treat the patient's condition.

ANS: A, B, C, D, E All of these are potential signs of an ethical dilemma.

4. Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.) a. Attending a meeting of the local chapter of the American Association of Critical- Care Nurses in which a continuing education program on sepsis is being taught b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c. Participating on the unit's nurse practice council d. Posting an article from Critical Care Nurse on the management of venous thromboembolism for your colleagues to read e. Using evidence-based strategies to prevent ventilator-associated pneumonia

ANS: A, B, C, D, E All answers are correct. Attending a program to learn about sepsis—Acquires and maintains current knowledge and competency in patient care. Collaborating with pastoral services—Collaborates with the health care team to provide care in a healing, humane, and caring environment. Posting information for others—Contributes to the professional development of peers and other health care providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A. "I will replace my nitroglycerin supply every 6 months." B. "I can take up to 5 tablets every 3 minutes for relief of my chest pain." C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B. "I can take up to 5 tablets every 3 minutes for relief of my chest pain."

The nurse recognizes which statement as a potential ethical issue? A. "The physician explained my mother's poor prognosis." B. "If the breathing machine is helping my mother, why is the doctor asking me about removing the breathing tube?" C. "My mother has designated my brother to make decisions." D. "Can I assist with some of my mother's care?"

B. "If the breathing machine is helping my mother, why is the doctor asking me about removing the breathing tube?"

The nurse would assess a patient with reports of chest pain for which clinical manifestations associated with a myocardial infarction (MI)? (Select all that apply.) A. Flushing B. Ashen skin C. Diaphoresis D. Nausea and vomiting E. S3 or S4 heart sounds

B. Ashen skin C. Diaphoresis D. Nausea and vomiting E. S3 or S4 heart sounds

A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for A. return of reflexes. B. bradycardia with hypoxemia. C. effects of sensory deprivation. D. fluctuations in body temperature.

B. bradycardia with hypoxemia. : Neurogenic shock is due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia, which are important clinical clues. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. These effects are generally associated with a cervical or high thoracic injury (T6 or higher). Injury or fracture below the level of C4 results in diaphragmatic breathing if the phrenic nerve is functioning. Even if the injury is below C4, spinal cord edema and hemorrhage can affect the function of the phrenic nerve and cause respiratory insufficiency. Hypoventilation almost always occurs with diaphragmatic respirations because of the decrease in vital capacity and tidal volume, which occurs as a result of impairment of the intercostal muscles. Cervical and thoracic injuries cause paralysis of abdominal muscles and often intercostal muscles. Therefore the patient cannot cough effectively enough to remove secretions, leading to atelectasis and pneumonia. An artificial airway provides direct access for pathogens, making bronchial hygiene and chest physiotherapy extremely important to reduce infection. Neurogenic pulmonary edema may occur secondary to a dramatic increase in sympathetic nervous system activity at the time of injury, which shunts blood to the lungs. In addition, pulmonary edema may occur in response to fluid overload.

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to A. breathe with respiratory support. B. drive a vehicle with hand controls. C. ambulate with long-leg braces and crutches. D. use a powered device to handle eating utensils

B. drive a vehicle with hand controls. A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; use wheelchair independently; and drive a car with powered hand controls (in some patients); attendant care 0 to 6 hours/day.

The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face.

B. triggers leading to facial discomfort. The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during the surgery." b. "I will have small incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."

B: "I will have small incisions in my leg where they will remove the vein." When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

B: "It is important not to suddenly stop taking the carvedilol." Patients who have been taking -adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking -adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

B: "Sexual activity uses about as much energy as climbing two flights of stairs." Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to verbal command to move but attempts to push away a painful stimulus. The nurse records the patients Glasgow Coma Scale score as a. 9 b. 11 c. 13 d. 15

B: 11 Rationale: The patient has a score of 3 for eye opening, 3 for the best verbal response, and 5 for best motor response.

When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

B: Ask about chest pain. The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

B: Attach the cardiac monitor. Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.

To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

B: Determine what kind of physical activities the patient usually enjoys. Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults. DIF: Cognitive Level: Apply (application) REF: 761 TOP: Nursing Process: Planning MSC:

Which statement by a 40-year-old patient who is being discharge from the ED after a concussion indicates a need for intervention by the nurse? a. I will return if I feel dizzy or nauseated b. I am going to drive home and go to bed c. I do not even remember being in an accident d. I can take acetaminophen for my headache

B: I am going to drive home and go to bed Rationale: Following a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion.

Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

B: Pallor and weakness of the right hand The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

B: Patient with stable angina whose chest pain has recently increased in frequency The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable.

Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

B: The pain has lasted longer than 30 minutes. Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

A hospitalized patient complains of a bilateral headache, 4/10 on the pain scale, that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially? a. lorazepam (Ativan) b. acetaminophen (Tylenol) c. Morphine sulfate (Roxanol) d. butalbital and aspirin (Fiorinal)

B: acetaminophen (Tylenol) Rationale: The patients symptoms are consistent with a tension headache, and initial therapy usually involves a nonopijoid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant.

When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events.

B: additional diagnostic testing will be required. Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

An unconscious 39-year-old male patient is admitted to the ED with a head injury. The patients spouse and teenage children stay at the patients side and ask many questions about the treatment being given. What action is best for the nurse to take? a. ask the family to stay in the waiting room until the initial assessment is completed b. allow the family to stay with the patient and briefly explain all procedures to them c. refer the family members to the hospital counseling service to deal with their anxiety d. call the family pastor or spiritual advisor to take them to the chapel while care is given

B: allow the family to stay with the patient and briefly explain all procedures to them Rationale: The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergency care needs.

To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor? a. do you have difficulty in hearing? b. are you experiencing visual problems? c. are you having any trouble with your balance? d. have you developed any weakness on one side?

B: are you experiencing visual problems? Rationale: Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision.

The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. cardiac monitor shows a heart rate of 61 beats/minute.

B: blood pressure is 90/54 mm Hg. Patients taking -adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. have the patient gently blow the nose b. check the drainage for glucose content c. teach the patient that rhinorrhea is expected after a head injury d. obtain a specimen of the fluid to send for culture and sensitivity

B: check the drainage for glucose content Rationale: Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid leakage. If the drainage is CSF, it will test positive for glucose.

Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. decrease spasm of the coronary arteries. c. increase the force of the heart contractions. d. help prevent plaque from forming in the coronary arteries.

B: decrease spasm of the coronary arteries. Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and -adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mmHg. which action should the nurse take first? a. document the increase in intracranial pressure b. ensure that the patients neck is in neutral position c. notify the health care provider about the change in pressure d. increase the rate of the prescribed propofol infusion

B: ensure that the patients neck is in neutral position Rationale: Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes.

A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will be too upsetting if I have a seizure at work. which response by the nurse is best? a. you might benefit from some psychology counseling b. epilepsy usually can be well controlled with medications c. you will want to contact the epilepsy foundation for assistance d. the department of vocational rehabilitation can help with work retraining

B: epilepsy usually can be well controlled with medications Rationale: The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other options may be necessary is seizures persist after treatment.

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a. expressive aphasia b. impaired judgement c. right-sided weakness d. difficulty swallowing

B: impaired judgement Rationale: The frontal lobe controls intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis, the nurse should a. assess for the presence of chest pain b. inquire about urinary tract problems c. inspect the skin for rashes or discoloration d. ask the patient about any increase in libido

B: inquire about urinary tract problems Rationale: Urinary tract problems with incontinence or retention are common symptoms of MS. A decrease in libido is common with MS.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patients nose. Which assessment order should the nurse question? a. keep the head of the bed elevated b. insert nasogastric tube to low suction c. turn patient side to side every 2 hours d. apply cold packs intermittently to face

B: insert nasogastric tube to low suction Rationale: Rhinorrhea may indicate a dural tear with cerebrospinal leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Other options are appropriate.

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine. An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. auscultate the patients bowel sounds b. notify the patients HCP c. administer the prescribed PRN antiemetic drug d. give the scheduled dose of prednisone

B: notify the patients HCP Rationale: The patients history and symptoms indicate a possible cholinergic crisis. The HCP should be notified and it is likely that atropine will be prescribed.

Which finding for a patient who has a head injury should the nurse report immediately to the HCP? a. intracranial pressure is 16 mmHg when patient is turned b. pale yellow urine output is 1200 mL over the last 2 hours c. LIXOC brain tissue oxygenation catheter shows PbtO2 of 38 mmHg d. ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours

B: pale yellow urine output is 1200 mL over the last 2 hours Rationale: The high urine output indicates that diabetes insipidus may be developing, and intervention to prevent dehydration need to be rapidly implemented.

The home health RN is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated t a LPN/LVN? a. make referrals to appropriate community agencies b. place medications in the home medication organizer c. teach the patient and family how to manage seizures d. assess for use of medications that may precipitate seizures

B: place medications in the home medication organizer Rationale: LPN/LVN education includes administration of medications. The other options require RN scope of practice.

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the ED. Which action will the nurse plan to take? a. administer IV furosemide b. prepare the patient for craniotomy c. initiate high-dose barbiturate therapy d. type and crossmatch for blood transfusion

B: prepare the patient fo craniotomy Rationale: The principle treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If ICP is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the herniation is removed.

Which action will the ED nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. coordinate the transfer of the patient to the operating room b. provide discharge instructions about monitoring neurologic status c. transport the patient to radiology for MRI d. arrange to admit the patient to the neurologic unit for 24 hours of observation

B: provide discharge instructions about monitoring neurologic status Rationale: A patient with a minor head trauma is usually discharge with instructions about neurologic monitoring and the need to return if neurologic status deteriorates.

A patient admitted with a diffuse axonal injury has a systemic BP of 106/52 mmHg and intracranial pressure of 14 mmHg. Which action should the nurse take first? a. document the BP and ICP in the patients record b. report the BP and ICP to the HCP c. elevate the head of the patients bed to 60 degrees d. continue to monitor the patients vital signs and ICP

B: report the BP and ICP to the HCP Rationale: Immediate changes in the patients therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the ED. Which action prescribed by the HCP should the nurse question? a. elevate the head of the bed 20 degrees b. restrict oral fluids to 1000mL daily c. administer ceftriaxone (Rocephin) 1G IV every 12 hours d. give ibuprofen 400mg every 6 hours as needed for headache

B: restrict oral fluids to 1000mL daily Rationale: The patient with meningitis has increased fluid needs, so oral fluids should be encouraged.

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome who is having difficulty sleeping? a. teach about the use of antihistamines to improve sleep b. suggest that the patient exercise regularly during the day c. make a referral to a massage therapist for deep massage of the legs d. assure the patient that the problem is transient and likely to resolve

B: suggest that the patient exercise regularly during the day Rationale: Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS.

a 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to Bradykinesia. which action will the nurse include in the plan of care? a. instruct the patient in activities that can be done while lying or sitting b. suggest that the patients rock from side to side to initiate leg movement c. have the patient take small steps in a straight line directly in front of the feet d. teach the patient to keep in contact with the floor and slide them forward

B: suggest that the patient rock from side to side to initiate leg movement Rationale: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

Which action will the nurse plan to take for a 40-year-old patient with MS who has urinary retention caused by a flaccid bladder? a. decrease the patients evening fluid intake b. teach the patient how to use the Cred method c. suggest the use of adult incontinence briefs for nighttime only d. assist the patient to the commode every 2 hours during the day

B: teach the patient how to use the Cred method Rationale: The Cred method can be used to improve bladder emptying.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a. Pulse 102 beats/min b. Temperature 101.6° F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

B: temperature 101.6F Rationale: Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor.

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. this type of monitoring system is complex and it is managed by skilled staff b. the monitoring system helps show whether blood flow to the brain is adequate c. the ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure d. this monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage

B: the monitoring system helps show whether blood flow to the brain is adequate Rationale: Short and simple explanations should be given initially to patients and family members.

The nurse will assess a 67-year-old patient who is experiencing a cluster headache for a. nuchal rigidity b. unilateral ptosis c. projectile vomiting d. throbbing, bilateral facial pain

B: unilateral ptosis Rationale: Unilateral eye edema, tearing, and ptosis are characteristics of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increase intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect some nausea as a side effect of nitroglycerin." b. "I should only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."

C : "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved after 3 sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

In caring for the patient with angina, the patient said, "While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, then the pain went away." What further assessment data should the nurse obtain from the patient? A. "What precipitated the pain?" B. "Has the pain changed this time?" C. "In what areas did you feel this pain?" D. "What is your pain level on a 0 to 10 scale?"

C. "In what areas did you feel this pain?"

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication? A. Dehydration B. Paralytic ileus C. Atrial dysrhythmias D. Acute respiratory distress syndrome

C. Atrial dysrhythmias

Which therapy or treatment often falls between ordinary and extraordinary care? A. Intravenous fluids at 100 mL/hr B. Puréed diet for nutrition C. Feeding tube for hydration D. Renal dialysis

C. Feeding tube for hydration A feeding tube for nutrition and hydration falls between ordinary and extraordinary care. IV fluids and a puréed diet are considered ordinary care. Dialysis is extraordinary treatment

During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? A. A heart rate of 92 B. A reddened area over the patient's coccyx C. Marked perspiration on the patient's face and arms D. A light inspiratory wheeze on auscultation of the lungs

C. Marked perspiration on the patient's face and arms Autonomic dysreflexia is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It occurs in response to visceral stimulation once spinal shock is resolved in patients with spinal cord lesions. The condition is a life-threatening situation that requires immediate resolution. If resolution does not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/min), piloerection (erection of body hair) as a result of pilomotor spasm, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea.

A 74 year old man with a history of prostate cancer & hypertension presents to the ED with substernal chest pain. What priority action will the nurse complete before administering sublingual NTG? A. Administer morphine sulfate B. Listen to heart & lung sounds C. Obtain a 12-lead ECG D. Assess for CAD risk factors

C. Obtain a 12-lead ECG If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will check my pulse rate before I take any nitroglycerin tablets." b. "I will put the nitroglycerin patch on as soon as I get any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."

C: "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

C: "What time did your chest pain begin?" Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.

A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

C: Auscultate for a pericardial friction rub. The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).

C: Bilateral crackles are auscultated in the mid-lower lobes. The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

After reviewing information shown in the accompanying figure from the medical records of a 43-year-old, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Ongoing cardiac risk associated with history of tobacco use

C: Dietary changes to improve lipid levels The patient has an elevated low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol, which will increase the risk of coronary artery disease. Although the blood pressure is in the prehypertensive range, the patient's waist circumference and body mass index (BMI) indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.

A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV

C: Electrocardiogram (ECG) The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI). Peripheral access will be needed but not before the ECG.

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.

C: Heart rate increases from 66 to 92 beats/minute. A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

C: Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation. b. Heparin decreases coronary artery plaque size. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

C: Heparin prevents the development of new clots in the coronary arteries. Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. I can take the Topamax as soon as a headache starts b. a glass of wine might help me relax and prevent a headache c. I will lie down someplace dark and quiet when the headache begin d. I should avoid taking aspirin and sumatriptan at the same time

C: I will lie down someplace dark and quiet when the headache begin Rationale: It is recommended that the patient with a migraine rest in a dark, quiet area. Topamax is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other NSAIDs can be taken with the triptans.

The nurse has administered prescribed IV mannitol to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiveness? a. BP b. O2 saturation c. Intracranial pressure d. Hemoglobin and hematocrit

C: Intracranial pressure Rationale: Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. it may initially reduce hematocrit and increase BP, but these are not the best parameters for evaluation of the effectiveness of the drug.

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

C: ST-segment elevation The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.

During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

C: a decrease in level of consciousness. The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

A 22-year-old patient seen at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. teach about the use of triptan drugs b. refer the pattern for stress counseling c. ask the patient to keep a heading diary d. suggest the use of muscle-relaxation techniques

C: ask the patient to keep a headache diary Rationale: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of the pain, etc.

A patient has increased intracranial pressure and ventriculostomy after a head injury. Which action can the nurse delegate to UAP who regularly work in the ICU? a. document intracranial pressure every hour b. turn and reposition the patient every 2 hours c. check capillary blood glucose level every 6 hours d. monitor cerebrospinal fluid color and volume hourly

C: check capillary blood glucose level every 6 hours Rationale: Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill.

When a brain-injured patient responds to nail bed pressure with internal rotations, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal b. localization of pain c. decorticate posturing d. decerebrate posturing

C: decorticate posturing Rationale: Internal rotations, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

A 49-year-old patient with MS is to begin treatment with glatiramete acetate. Which information will the nurse include in patient teaching? a. recommendation to drink at least 4L of fluid daily b. need to avoid driving or operating heavy machinery c. how to draw up and administer injections of the medication d. use of contraceptive methods other than oral contraceptives

C: how to draw up and administer injections of the medication Rationale: Copaxone is admitted by self-injection. Oral contraceptives are an appropriate choice for birth control.

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. encourage adolescents and young adults to avid crowds in the winter b. vaccinate 11 and 12-year-old children again Haemophilus influenza c. immunize adolescents and college freshman against Neisseria menigitides d. emphasize the importance of hand washing to prevent the spread of infection

C: immunize adolescents and college freshman against Neisseria menigitides Rationale: The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshman. Hand washing may help decrease the spread of bacteria, but is it not effective as immunization.

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. encourage coughing and deep breathing b. position the patient with knees and hips flexed c. keep the head of the bed elevated to 30 degrees d. cluster nursing interventions to provide rest periods

C: keep the head of the bed elevated to 30 degrees Rationale: The patient with increased intracranial pressure should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP.

A 40-year-old patient is diagnosed with early Huntingtons disease. When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa to help reduce HD symptoms b. prophylactic antibiotics to decrease the risk for aspiration pneumonia c. option of genetic testing for the patients children to determine their own HS risks d. lifestyle changes of improved nutrition and exercise that delay disease progression

C: option of genetic testing for the patients children to determine their own HS risks Rationale: Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine.

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. intracranial pressure of 15 mmHg b. cerebrospinal fluid drainage of 25 mL/hr c. pressure of oxygen in brain tissue is 14 mmHg d. cardiac monitor shows sinus tachycardia at 12 bpm

C: pressure of oxygen in brain tissue is 14 mmHg Rationale: The PbtO2 should be 20-40 mmHg. Lower levels indicate brain ischemia. An Intracranial pressure of 15 mmHg is at the upper limit of normal.

A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to a. lower heart rate. b. control blood glucose levels. c. prevent changes in heart muscle. d. reduce the frequency of chest pain.

C: prevent changes in heart muscle. The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. pupil size b. grip strength c. respiratory effort d. LOC

C: respiratory effort Rationale: Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other options are not as critical.

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? a. the apical pulse is slightly irregular b. the patient complains of a headache c. the patient is more difficult to arouse d. the BP increases to 140/62 mmHg

C: the patient is more difficult to arouse Rationale: The change in LOC is an indicator of ICP and suggests that action bu the nurse is needed to prevent complications.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.

C: the staff nurse suctions the patient routinely every 2 hours Rationale: Suctioning increases intracranial pressure, and should only be done when the patients respiratory condition indicates it is needed.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. insert an oral airway during the seizure to maintain a patient airway b. restrain the patients arms and legs to prevent injury during the seizure c. time and observe and record the details of the seizure and postictal state d. avoid touching the patient to prevent further nervous system stimulation

C: time and observe and record the details of the seizure and postictal state Rationale: Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

The nurse recognizes which situation may warrant an ethics consultation? A. "We've met as a family and agree that we should withdraw life support." B. "My mother has designated her minister as her health care surrogate." C. "We've met as a family and want mother to be resuscitated if her heart stops." D. "Mother never got around to completing her living will, so I think she would want everything done. My brother disagrees."

D. "Mother never got around to completing her living will, so I think she would want everything done. My brother disagrees." Answers A through C show consensus and communication. Answer D identifies a potential conflict because the patient does not have an advance directive. Waze for nurses to increase ethical decision making starts with open communication with the healthcare team, patient, and family regarding patient wishes and ethical concerns. The purpose of ethics consultation is to improve the process and outcome of patient care I hoping identify analyze and resolve ethical problems.

The patient is being dismissed from the hospital after acute coronary syndrome (ACS) and will be attending rehabilitation. What information would be taught in the early recovery phase of rehabilitation? A. Therapeutic lifestyle changes should become lifelong habits. B. Physical activity is always started in the hospital and continued at home. C. Attention will focus on managing chest pain, anxiety, dysrhythmias, and other complications. D. Activity level is gradually increased under cardiac rehabilitation team supervision and monitoring

D. Activity level is gradually increased under cardiac rehabilitation team supervision and monitoring

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? A. Chronic stable angina B. Left-sided heart failure C. Coronary artery disease D. Acute myocardial infarction

D. Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and coronary artery disease are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

During report using SBAR, the nurse states, "Since we have just initiated a potassium replacement protocol, the patient will need a potassium level drawn at 1300." This depicts: A. Situation B. Background C. Assessment D. Recommendation

D. Recommendation

Which of the following is associated with high levels of noise in the critical care unit? A. Alcohol withdrawal syndrome B. Hypotension C. Normal oxygen saturation D. Sleep disruptions

D. Sleep disruptions

The charge nurse assigns patients based on their acuity and the level of experience of the critical care nurses on duty. This is an example of implementation of: A. SBAR communication B. Healthy work environment C. National patient safety goals D. Synergy model

D. Synergy model

Being present during a code can assist family members in: A. Determining the need for a lawsuit B. Documenting care that was provided C. Taking a photo of the family member D. Witnessing that everything has been done

D. Witnessing that everything has been done

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

D: "I will miss being able to eat peanut butter sandwiches." Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

D: 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI) This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

D: Cardiac-specific troponin Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale

D: Chest pain level 7 on a 0 to 10 point scale The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

D: Decreased cardiac output related to cardiogenic shock All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication? a. Have the patient take this medication with an aspirin. b. Administer the medication at the patient's usual bedtime. c. Have the patient take the colesevelam with a sip of water. d. Give the patient's other medications 2 hours after the colesevelam.

D: Give the patient's other medications 2 hours after the colesevelam. The bile acid sequestrants interfere with the absorption of many other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals.

A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications

D: Reinforcement of teaching about the purpose of prescribed medications LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs

D: Tachypnea and crackles in lungs Pulmonary congestion and tachypnea suggest that the patient may be developing heart failure, a complication of myocardial infarction (MI). Mild fever and hyperglycemia are common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient states that the pain "wakes me up at night." b. The patient rates the pain at a level 3 to 5 (0 to 10 scale). c. The patient states that the pain has increased in frequency over the last week. d. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.

D: The patient states that the pain "goes away" with one sublingual nitroglycerin tablet. Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. the bedrails at the head and foot of the bed are both elevated b. the patient receives a regular diet from the dietary department c. the lights in the patients room are turned off and blinds are shut d. unliences assistive personnel enter the patients room without a mask

D: UAP enter the patients room without a mask Rationale: Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed.

After the ED 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 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 second 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 Rationale: The dilated and non-responsive pupil may indicate an inctracerebral hemorrhage and increased intracranial pressure.

Which prescribed intervention will the nurse implement first for a patient in the ED who is experiencing continuous tonic-clonic seizures? a. give phenytoin 100mg IV b. monitor LOC c. obtain CT scan d. administer lorazepam (Ativan 4mg IV

D: administer lorazepam Rationale: To prevent ongoing seizures, the nurse should administer rapidly acting anti seizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary.

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids b. antiparkinsonian drugs c. MRI d. EEG testing

D: antiparkinsonian drugs Rationale: The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered.

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. multivitamin b. acetaminophen c. ibuprofen d. diphenhydramine

D: dipenhydramine Rationale: Antihistamines can aggravate restless legs syndrome.

1. When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. increased risk of cardiovascular disease as people age. d. elevation of the patient's low-density lipoprotein (LDL) level.

D: elevation of the patient's low-density lipoprotein (LDL) level. Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. activity intolerance b. self-care deficits: toileting c. ineffective self-health management d. imbalanced nutrition: less than body requirements

D: imbalanced nutrition: less than body requirements Rationale: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing.

Which information about a 72-year-old patient who has a new prescription for phenytoin indicates that the nurse should consult with the HCP before administration of the medication? a. patient has generalized tonic-clonic seizures b. patients experiences an aura before seizures c. patients most recent blood pressure is 156/92 mmHg d. patient has minor elevations in the liver function tests

D: patient has minor elevations in the liver function tests Rationale: Many older patients may not be able to metabolize phenytoin. The HCP may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with Tonic-clonic seizures, with or without an area.

After having a craniotomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods b. turn and reposition the patient side to side every 2 hours c. position the bed flat and log roll to reposition the patient d. perform ROM exercises every 4 hours

D: perform ROM exercises every 4 hours Rationale: ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniotomy should not be turned to the operative side.

A patient being admitted with bacterial meningitis has a temperature of 102.5F and a severe headache. Which order for collaborative intervention should the nurse implement first? a. administer ceftizoxime (Cefizox) 1g IV b. give acetaminophen 650mg PO c. use a cooling blanket to lower temperature d. swab the nasopharyngeal mucosa for cultures

D: swab the nasopharyngeal mucosa for cultures Rationale: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a. complaint of severe headache b. large contusion behind left ear c. bilateral periorbital ecchymosis d. temperature of 101.4 F

D: temperature of 101.4 F Rationale: Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the HCP.

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. the ability to do daily activities without chest pain.

D: the ability to do daily activities without chest pain. Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective -adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the HCP before giving the prescribe dose of Dalfampridine? a. the patient has relapsing-remitting MS b. the patient walks a mile a day for exercise c. the patient complains of pain with neck flexion d. the patient has an increased serum creatinine level

D: the patient has an increased serum creatinine level Rationale: Dalfampridine should not be given to patients with impaired renal function.

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the HCP? a. the patient exhibits nuchal rigidity b. the patient has a positive Kernings sign c. the patients temperature is 101 F d. the patients BP is 88/42 mmHg

D: the patients BP is 88/42 mmHg Rationale: Shock is a serious complications of meningitis, and the patterns low BP indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernings sign are expected with bacterial meningitis.

A 62-year-old patient who has Parkinson's disease is taking bromocriptine. Which information obtained by the nurse may indicate a need for a decrease in the dose? a. the patient has a chronic dry cough b. the patient has four loose stools in a day c. the patient develops a DVT d. the patients BP is 95/52 mmHg

D: the patients BP is 92/52 mmHg Rationale: Hypotension is an adverse effect of bromocriptine, and the nurse should check with the HCP before giving the medication. The other options are not associated.

A 76-year-old patient is being treated with carbidopa/levodopa for Parkinson's disease. Which information is most important for the nurse to report to the HCP? a. shuffling gait b. tremor at rest c. cogwheel rigidity of limbs d. uncontrolled head movement

D: uncontrolled head movement Rationale: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other options are typical.

5. The nurse is caring for an 80-year-old patient who has been treated for gastrointestinal bleeding. The family has agreed to withhold additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued. The nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.) a. "Do not resuscitate." b. Change antibiotic to a less expensive medication. c. Discontinue tube feeding. d. Stop any further blood transfusions. e. Water boluses every 4 hours with tube feeding.

a. "Do not resuscitate." d. Stop any further blood transfusions. e. Water boluses every 4 hours with tube feeding. ANS: A, D, E A DNR order would be appropriate given the family's decision, as would prohibiting further transfusions. Giving water boluses is compatible with the patient's wishes, but stopping the feeding is not. Changing antibiotics may or may not be appropriate, but the cost of treatment is not related to the withholding of further care.

29. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. "I have an incredible headache!" b. "There is blood on my toothbrush!" c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"

a. "I have an incredible headache!" ANS: A The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. The worst complication is intracranial bleeding. Any neurological signs and symptoms must be taken seriously, and all fibrinolytic and/or heparin therapies must be discontinued until this is ruled out.

6. The patient tells the nurse, "I didn't think I was having a heart attack because the pain was in my neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel." e. "Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911."

a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." ANS: A, B, C Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck. In the statement about treating symptoms with nitroglycerin, the word "several" is vague.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

a. "The obstructing plaque is surgically removed from an artery in the neck." ANS: A In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

12. Elderly patients who require critical care treatment are at risk for increased mortality, functional decline, or decreased quality of life after hospitalization. Assuming each of these patients was discharged from the hospital, which of the following patients is at greatest risk for decreased functional status and quality of life? a. A 70-year-old man who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term acute care hospital. He is a widower. b. A 79-year-old woman admitted for exacerbation of heart failure. She manages her care independently but needed diuretic medications adjusted. She states that she is compliant with her medications but sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves to be indep

a. A 70-year-old man who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term acute care hospital. He is a widower. ANS: A Although he is younger, the 70-year-old with the complicated critical care course, limited social support, and a transfer to a long-term acute care facility is at greatest risk for decreased quality of life and functional decline. He will continue to need high-level nursing care and support for rehabilitation. The other cases are examples of individuals with shorter hospital stays, uncomplicated courses, and social support systems.

17. Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal cord injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

a. A patient with a complete spinal cord injury at the C5 dermatome level ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

1. Which of the following is a National Patient Safety Goal? (Select all that apply.) a. Accurately identify patients. b. Eliminate the use of patient restraints. c. Reconcile medications across the continuum of care. d. Reduce risks of health care-acquired infection. e. Reduce costs associated with hospitalization.

a. Accurately identify patients. c. Reconcile medications across the continuum of care. d. Reduce risks of health care-acquired infection. ANS: A, C, D All except for eliminating the use of restraints and reducing costs are current National Patient Safety Goals. Hospitals have policies regarding the use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal. Many facilities are actively working on cost reduction, but this is not a National Patient Safety Goal either.

7. The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.) a. Adjust lighting to promote normal sleep-wake cycles. b. Provide clocks, calendars, and personal photos in the patient's room. c. Talk to the patient about other patients you are caring for on the unit. d. Tell the patient the day and time when you are providing routine nursing interventions. e. Allow unlimited visitation tailored to the patient's individual needs.

a. Adjust lighting to promote normal sleep-wake cycles. b. Provide clocks, calendars, and personal photos in the patient's room. e. Allow unlimited visitation tailored to the patient's individual needs. ANS: A, B, E Manipulation of the environment, such as the adjustment of lighting, is helpful in promoting sleep and rest. Clocks, calendars, photos, and other personal items promote orientation and personalize the environment; telling the patient the day and time and other current events assists in maintaining the patient's orientation. Allowing visitation that best meets the patient's needs will reduce stress as the patient's support systems are present. Conversations about other patients are private and should take place away from other patients.

16. A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels to at least 88% d. Maintain heart rate above 100 beats/min

a. Administer thrombolytic therapy unless contraindicated ANS: A Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Because interventional cardiology is unavailable, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.

2. Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply.) a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy e. Transfusion of packed red blood cells

a. Administration of morphine b. Administration of nitroglycerin (NTG) d. Oxygen therapy ANS: A, B, D The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct. Transfusion is not required except in the setting of severe anemia, which may limit oxygen delivery to the heart. Dopamine infusion is usually used to treat hypotension but causes tachycardia which would be deleterious for the patient having an AMI because it increases the heart's workload and demand for oxygen.

5. The critical care environment is often stressful to a critically ill patient. Identify stressors that are common. (Select all that apply.) a. Alarms that sound from various devices b. Bright fluorescent lighting c. Lack of day-night cues d. Sounds from the mechanical ventilator e. Visiting hours tailored to meet individual needs

a. Alarms that sound from various devices b. Bright fluorescent lighting c. Lack of day-night cues d. Sounds from the mechanical ventilator ANS: A, B, C, D Adjustment of visiting hours to meet the needs of patients and families assists in reducing the stress of critical illness. All other responses are environmental stressors that may increase anxiety or affect sleep.

4. It is important for critically ill patients to feel safe. Which nursing strategies help the patient to feel safe in the critical care setting? (Select all that apply.) a. Allow family members to remain at the bedside. b. Consult with the charge nurse before making any patient care decisions. c. Provide informal conversation by discussing your plans for after work. d. Respond promptly to call bells or other communication for assistance. e. Inform the patient that you have cared for many similar patients.

a. Allow family members to remain at the bedside. d. Respond promptly to call bells or other communication for assistance. ANS: A, D Patients feel safe when nurses exhibit technical competence, meet their needs, and provide reorientation. Family member presence may also contribute to feeling safe. Consulting with the charge nurse before making decisions may be interpreted as incompetence or insecurity. The nurse's personal activities should never be discussed with patients. Simply informing the patient that you have cared for many similar patients may or may not cause the patient to feel safer; the patient may feel this is condescending.

6. Which strategy is important in addressing issues associated with the aging workforce? (Select all that apply.) a. Allowing nurses to work flexible shift durations b. Encouraging older nurses to transfer to an outpatient setting that is less stressful c. Hiring nurse technicians who are available to assist with patient care, such as turning the patient d. Remodeling patient care rooms to include devices to assist in patient lifting e. Developing a staffing model that accurately reflects the unit's needs.

a. Allowing nurses to work flexible shift durations c. Hiring nurse technicians who are available to assist with patient care, such as turning the patient d. Remodeling patient care rooms to include devices to assist in patient lifting ANS: A, C, D Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including both registered nurses and nonlicensed assistive personnel to help with nursing and nonnursing tasks, is helpful. Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group.

1. Which of the following professional organizations best supports critical care nursing practice? a. American Association of Critical-Care Nurses b. American Heart Association c. American Nurses Association d. Society of Critical Care Medicine

a. American Association of Critical-Care Nurses ANS: A The American Association of Critical-Care Nurses is the specialty organization that supports and represents critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical care team under the direction of an intensivist.

2. Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.) a. American Journal of Critical Care b. Critical Care Clinics of North America c. Critical Care Nurse d. Critical Care Nursing Quarterly e. Critical Care Nursing Management

a. American Journal of Critical Care c. Critical Care Nurse ANS: A, C American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics, Critical Care Nursing Quarterly, and Critical Care Nursing Management are not AACN publications.

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

a. Apply intermittent pneumatic compression stockings. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting up that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

3. Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the critical care setting? (Select all that apply.) a. Ask the family to bring in the patient's iPod or other device with favorite music. b. Invite a volunteer harpist to play on the unit on a regular basis. c. Remodel the unit to have two-patient rooms to facilitate nursing care. d. Remodel the unit to install acoustical ceiling tiles. e. Turn the volume of equipment alarms as low as they can be adjusted, and "off" if possible.

a. Ask the family to bring in the patient's iPod or other device with favorite music. b. Invite a volunteer harpist to play on the unit on a regular basis. d. Remodel the unit to install acoustical ceiling tiles. ANS: A, B, D A personal device with favorite music and headphones can be helpful in reducing ambient unit noise. Music therapy programs, such as harpists, can provide soothing sedative music that is often comforting to both patients and family members. Acoustical tiles help to reduce noise in the critical care setting and should be included in remodeling plans as well as new unit construction. Multiple patients in a single room would increase noise levels and contribute to an increased risk of infection. Alarms on critical equipment must never be turned off. The volume should be loud enough that the alarm can be heard by the nurse if outside the room. The lowest setting may not be loud enough, depending on the unit layout and patient assignment.

Which action will the nurse include in the plan of care for a 62-year-old patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient.

a. Assess fluid and dietary intake. The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

10. Which of the following statements about family assessment is false? a. Assessment of structure (who comprises the family) is the last step in assessment. b. Interaction among family members is assessed. c. It is important to assess communication among family members to understand roles. d. Ongoing assessment is important, because family functioning may change during the course of illness.

a. Assessment of structure (who comprises the family) is the last step in assessment. ANS: A Assessment of structure should be done first so that the nurse can identify such things as who comprises the family and who assumes leadership and decision-making responsibilities. This assessment also assists in identifying which individuals are most important to the patient and how many people may be seeking information. Family member interaction must be assessed, so this answer is true. Family member communication must be assessed, so this answer is true. Ongoing assessment of family is necessary as functions may change, so this answer is true.

13. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient's mouth and insert a padded tongue blade. d. Restrain the patient's extremities until the seizure subsides.

a. Assist the patient to the floor and provide soft head support. ANS: A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient's jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care.

2. A critically ill patient has a living will in the chart. The patient's condition has deteriorated, but the spouse wants "everything done," regardless of the patient's wishes. Which ethical principle is the spouse violating? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

a. Autonomy ANS: A Autonomy is respect for the individual and the ability of individuals to make decisions with regard to their own health and future. The spouse is violating the patient's autonomy in decision making. Beneficence consists of actions intended to benefit the patients or others. Justice means being fair. Nonmaleficence is the duty to prevent harm.

2. The nurse is caring for a patient whose condition has deteriorated and who is not responding to standard treatment. The physician calls for an ethical consultation with the family to discuss potential withdrawal of treatment versus aggressive treatment. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.) a. Burden versus benefit b. Family's wishes c. Patient's wishes d. Potential outcomes of treatment options e. Cost savings of withdrawing treatment

a. Burden versus benefit c. Patient's wishes d. Potential outcomes of treatment options ANS: A, C, D According to the ethical decision-making process, decisions should be made in light of the patient's wishes (autonomy), burden versus benefit (beneficence), other relevant principles, and potential outcomes of various options. The patient's wishes may differ from those of the family. Costs should not be considered; rather health care resources should be distributed in a way that ensures justice.

5. A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture e. Chest pain

a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture ANS: A, B, C, D Dysrhythmias, heart failure, pericarditis and ventricular rupture are potential complications of AMI. Chest pain is a possible symptom of AMI.

Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate several times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

a. Catheterize patient every 3 to 4 hours. Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate. The head and neck will not need to be stabilized following a cauda equina injury, which affects the lumbar and sacral nerve roots.

7. Which of the following strategies will assist in creating a healthy work environment for the critical care nurse? (Select all that apply.) a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party b. Implementing a medication safety program designed by pharmacists c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio d. Offering quarterly joint nurse-physician workshops to discuss unit issues e. Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication

a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party d. Offering quarterly joint nurse-physician workshops to discuss unit issues e. Using the Situation- Background-Assessment-Recommendation (SBAR) technique for handoff communication ANS: A, D, E Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work environment. Implementing a medication safety program enhances patient safety, but if done without nursing input, it could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly unneeded.

12. Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research? a. Clinical practice guidelines b. Computerized physician order entry c. Consulting with advanced practice nurses d. Implementing Joint Commission National Patient Safety Goals

a. Clinical practice guidelines ANS: A Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research. Some physician order entry pathways, but not all, are based on research recommendations. Some advanced practice nurses, but not all, are well versed in evidence-based practices. The National Patient Safety Goals are recommendations to reduce errors using evidence-based practices.

4. Sleep often is disrupted for critically ill patients. Which nursing intervention is most appropriate to promote sleep and rest? a. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. b. Encourage family members to talk with the patient whenever they are present in the room. c. Keep the television on to provide white noise and distraction. d. Leave the lights on in the room so that the patient is not frightened of his or her surroundings.

a. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. ANS: A Planning care to promote periods of uninterrupted rest is important. Consulting with the pharmacist to adjust a medication schedule is an excellent example of this intervention. It is important for family members to communicate with the patient; however, rest periods must be scheduled. Family members can be present in the room while remaining quiet during these scheduled times. The television may be useful if it is part of the patient's normal routine for sleep; however, it does not consistently provide white noise or distraction. Lights should be dimmed during scheduled rest periods and at night to facilitate sleep and rest.

13. The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 80% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

a. Coronary artery bypass graft surgery ANS: A Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%). The stent or PTCA are not appropriate because the patient is a candidate for CABG. The transmyocardial revascularization is reserved for patients who do not have other treatment options.

13. Patients often have recollections of the critical care experience. Which is likely to be the most common recollection of patients who required endotracheal intubation and mechanical ventilation? a. Difficulty in communicating b. Inability to get comfortable c. Pain d. Sleep disruption

a. Difficulty in communicating ANS: A Although the patient may recall all of these potential experiences, recollection of difficult communication is most likely secondary to the endotracheal tube placement.

1. A patient with a 10-year history of heart failure presents to the emergency department reporting severe shortness of breath. Assessment reveals crackles throughout the lung fields and labored breathing. The patient takes beta blockers, ACE inhibitors, and diuretics as directed. What treatment strategies does the nurse plan to implement for immediate short-term management? (Select all that apply.) a. Dobutamine b. Intraaortic balloon pump c. Nesiritide d. Ventricular assist device e. Biventricular pacemaker

a. Dobutamine b. Intraaortic balloon pump c. Nesiritide ANS: A, B, C This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump or insertion of a biventricular pacemaker also may be warranted as long-term therapy, but neither is appropriate for this acute exacerbation.

2. In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex. ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.

3. Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain.

a. Dysrhythmias are common occurrences. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain. ANS: A, C, D, E Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

16. The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that nurses are engaged and empowered to participate in ethical decision making. Which of the following would assist nurses in being involved in research studies? a. Education on protection of human subjects b. Participation of staff nurses on ethics committees c. Written descriptions of how nurses participate in ethics programs d. Written policies and procedures related to response to ethical issues

a. Education on protection of human subjects ANS: A Completion of education related to human subject protection assists nurses in research. Ethics committees, ethics programs, and policies address ethics issues rather than prepare nurses for research.

4. A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery

a. Emergent pacemaker insertion ANS: A The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by health care provider will the nurse question? a. Encourage oral fluids to 3 L/day b. Document neurologic symptoms c. Position patient lying on the side d. Observe respiratory status closely

a. Encourage oral fluids to 3 L/day The patient should be maintained on NPO status because neuromuscular weakness increases risk for aspiration. Side-lying position is not contraindicated. Assessment of neurologic and respiratory status is appropriate.

28. The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

a. Ensure patency of intravenous (IV) line. ANS: A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

2. The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best facilitate family-centered care? a. Ensure that the patient's room is large enough and has adequate space for a sleeper sofa and storage for family members' personal belongings. b. Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel far for testing. c. Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities such as coffee and tea. d. Provide access to a scenic garden for meditation.

a. Ensure that the patient's room is large enough and has adequate space for a sleeper sofa and storage for family members' personal belongings. ANS: A New unit design trends to promote family-centered care include patient rooms that provide a larger family space and comfortable furniture and storage to promote open visitation, including overnight stays in the patient's room. Ready access to diagnostic testing, including portable equipment, is an important trend; however, the purpose for this is to prevent the need for transport, not to foster family-centered care. A waiting room in close proximity to the unit with amenities is a nice feature; however, it does not need to be large if adequate space is incorporated into the patient's room. A scenic garden for meditation may assist in reducing family members' stress, but proximity to the patient is the greatest need.

2. Family presence is encouraged during resuscitation and invasive procedures. Which findings about this practice have been reported in the literature? (Select all that apply.) a. Families benefit by witnessing that everything possible was done. b. Families report reduced anxiety and fear about what is being done to the patient. c. Presence encourages family members to seek litigation for improper care. d. Presence reduces nurses' involvement in explaining things to the family. e. Families report that staff conversations during this time were distressing.

a. Families benefit by witnessing that everything possible was done. b. Families report reduced anxiety and fear about what is being done to the patient. ANS: A, B Families benefit from witnessing procedures and resuscitation. The presence of family members removes doubt about the patient's condition, allows them to witness that everything was done, and decreases anxiety about what is occurring. Increased litigation has not been associated with family presence. Policies and procedures are needed to facilitate family presence. A facilitator is needed, and it may initially require more nursing involvement. It does not eliminate nurses' responsibility for communicating with the family. The literature does not report that families have reported feelings of distress over staff conversations during these times.

1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range-of-motion to extremities d. Frequent oropharyngeal suctioning

a. Frequent neurological assessments NS: A Nurses complete neurological assessments based on prescribed frequency and the severity of the patient's condition. The newly admitted patient has an altered neurological status, so frequent neurological assessments are most important to include in the patient's plan of care. Side to side position changes, range-of-motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient's plan of care, but in the setting of increased intracranial pressure they should not be regularly performed unless indicated.

31. The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports before use. d. Dispose of all bloody dressings in biohazard bags.

a. Implement droplet precautions upon admission. ANS: A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing of all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

21. A patient has been diagnosed with Marfan syndrome. What information does the nurse plan to teach the patient about this condition? a. It is an autosomal dominant inherited disorder of connective tissue. b. It is caused by a random genetic mutation and is not familial. c. There are no drugs that help control the cardiac symptoms of the disease. d. Contact sports are permitted if precautions against concussion are taken.

a. It is an autosomal dominant inherited disorder of connective tissue. ANS: A Marfan syndrome is an autosomal dominant inherited disorder of connective tissue with a definite familial pattern. Beta blockers and ACE inhibitors are commonly used to treat the condition. Contact sports and weight lifting are generally prohibited.

7. Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. Jugular venous distension b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses e. Hepatomegaly

a. Jugular venous distension b. Peripheral edema e. Hepatomegaly ANS: A, B, E Jugular venous distension, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure. Crackles are indicative of left ventricular failure. Weak peripheral pulse are not a manifestation of right ventricular failure. Crackles are indicative of left sided failure.

3. The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.

a. Make frequent neurological assessments. c. Maintain MAP less than 130 mm Hg. ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

21. The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous

a. Mannitol 1 g intravenous ANS: A The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.

9. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patient's airway patency. b. Elevate the head of the patient's bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.

a. Monitor the patient's airway patency. ANS: A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient's airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority.

A nurse who works on the neurology unit just received change-of-shift report. Which patient will the nurse assess first? a. Patient with botulism who is experiencing difficulty swallowing b. Patient with Bell's palsy who has herpes vesicles in front of the ear c. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes d. Patient with an abscess caused by injectable drug use who needs tetanus immune globulin

a. Patient with botulism who is experiencing difficulty swallowing The patient's diagnosis and difficulty swallowing indicate that the nurse should rapidly assess for respiratory distress. The information about the other patients is consistent with their diagnoses and does not indicate any immediate need for assessment or intervention.

1. The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction (MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels

a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels ANS: A ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.

A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

a. The patient has new onset weakness of both legs. The new onset of symptoms indicates cord compression, which is an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.

12. A patient presents to the ED complaining of severe substernal chest pressure radiating to the left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI. d. Thrombolysis should be started immediately.

a. The patient is not a candidate for thrombolysis. ANS: A To be eligible for thrombolysis, the patient must be symptomatic for less than 12 hours. Therefore, this patient is not a candidate for this therapy.

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blockers

a. Urinary catheter care c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blockers The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine.

4. The nurse is caring for a patient with severe neurological impairment following a massive stroke. The physician has ordered tests to determine brain death. The nurse understands that criteria for brain death include (Select all that apply.) a. absence of cerebral blood flow. b. absence of brainstem reflexes on neurological examination. c. Cheyne-Stokes respirations. d. flat electroencephalogram. e. responding only to painful stimuli.

a. absence of cerebral blood flow. b. absence of brainstem reflexes on neurological examination. d. flat electroencephalogram. ANS: A, B, D Criteria for brain death include absence of cerebral blood flow, absence of brainstem reflexes, and flat electroencephalograph. The presence of Cheyne-Stokes respirations and the response to pain would indicate some brain function.

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

a. ask questions that the patient can answer with "yes" or "no". Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

6. To reduce relocation stress in patients transferring out of the intensive care unit, the nurse can (Select all that apply.) a. ask the nurses on the intermediate care unit to give the family a tour of the new unit. b. contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. c. ensure that the patient will be located near the nurses' station in the new unit. d. invite the nurse who will be assuming the patient's care to meet with the patient and family in the critical care unit prior to transfer. e. help the patient and family focus on the positive meaning of a transfer.

a. ask the nurses on the intermediate care unit to give the family a tour of the new unit. d. invite the nurse who will be assuming the patient's care to meet with the patient and family in the critical care unit prior to transfer. e. help the patient and family focus on the positive meaning of a transfer. ANS: A, D, E Patients often have stress when they are moved from the safety of the critical care unit. Introducing the patient and his family to the nurse who will assume care and to the new environment are strategies to reduce relocation stress. Encouraging the patient and family to see the transfer as a positive sign of healing might lessen the stress they feel. Although the patient and his family may feel safer in a room near the nurses' station, bed placement is determined by a variety of factors and cannot be guaranteed. Beds in the critical care unit are at a premium, and once the physician has determined that the patient no longer meets critical care admission requirements, it is essential that transfers be made as soon as a bed on the intermediate care unit is available.

14. As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a a. bundle of care. b. clinical practice guideline. c. patient safety goal. d. quality improvement initiative.

a. bundle of care. ANS: A A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines and are monitored for compliance as part of quality improvement initiatives. At some point, these may become part of patient safety goals.

17. A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications before admission for: a. erectile dysfunction. b. prostate enlargement. c. asthma. d. peripheral vascular disease.

a. erectile dysfunction. ANS: A A history of the patient's use of sildenafil citrate or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies. The other conditions would not be a contraindication for nitroglycerin.

A 32-year-old pregnant patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to a. respect the patient's feelings and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patient's concerns with visitors who arrive at mealtimes.

a. respect the patient's feelings and arrange for privacy at mealtimes. The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

a. risk for injury related to denial of deficits and impulsiveness. The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability

A 27-year-old patient who has been treated for status epileptics in the ED will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patients assigned room? Select all that apply. a. side-rail pads b. tongue blade c. oxygen mask d. sucking tubing e. urinary catheter f. nasogastric tube

a. side-rail pads c. oxygen mask d. sucking tubing Rationale: The patient is at risk for further seizures, and oxygen and suctioning may be needed for any seizures to clear the airway and maximize oxygenation. The bed side rails should be padded to minimize the risk for patient injury during a seizure.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care? Select all that apply. a. use an elevated toilet seat b. cut patients food into small pieces c. provide high-protein foods at each meal d. place an armchair at the patients bedside e. observe for sudden exacerbation of symptoms

a. use an elevated toilet seat b. cut patients food into small pieces d. place an armchair at the patients bedside Rationale: Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toiled seat will facilitate getting on and off the toilet.

22. The patient's spouse is feeling overwhelmed about cooking different dinners for the patient and the rest of the family to satisfy a cholesterol-reducing diet. Which response by the nurse is best? a. "It will be worth it to have a healthy spouse, won't it?" b. "The low-cholesterol diet is one from which everyone can benefit." c. "As long as you change at least a few things in the diet, it will be okay." d. "You can go on the diet with him, and then let the children eat whatever they want."

b. "The low-cholesterol diet is one from which everyone can benefit." ANS: B Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease. It will be easier if the family members all eat the same type of meal, so the nurse should suggest this option. Asking whether it's worth the trouble is not giving the spouse any information with which to make decisions. A diet low in cholesterol requires changing more than just a few things.

24. Which comment by the patient indicates a good understanding of a diagnosis of coronary heart disease? a. "I had a heart attack because I work too hard, and it puts too much strain on my heart." b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c. "If I change my diet and exercise more, I should get over this and be healthy." d. "What kind of pills can you give me to get me over this and back to my lifestyle?"

b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." ANS: B Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion. Stress and strain can increase the heart's oxygen demands but do not typically cause coronary artery disease. Coronary artery disease is a chronic illness. The patient asking for pills and a return to a previous lifestyle does not understand how risk factors lead to coronary artery disease.

28. A patient is having a stent and asks why it is necessary after having an angioplasty. Which response by the nurse is best? a. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."

b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." ANS: B Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.

11. The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline. What is the official time of death recorded in the medical record? a. 1300 b. 1330 c. 1400 d. 1800 e. 1810

b. 1330 ANS: B The time of death is when brain death is confirmed and documented in the chart, even though the patient's heart is still beating. Organs are retrieved after brain death has been documented.

29. The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the provider prescriptions, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push

b. 500 mL albumin intravenous infusion ANS: B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.

6. Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict? a. A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter's boyfriend for causing the accident. b. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have a written advance directive. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year. c. A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his heal

b. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have a written advance directive. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year. ANS: B Each of these situations may result in family conflict. The situation with the unmarried 36-year-old male without a written advance directive results in his distant parents being legally responsible for his health care decisions. Because of his long-standing commitment with his partner and lack of recent contact with his parents, this scenario is likely to cause the most conflict. The parents may make decisions based on their wishes, as they may not be knowledgeable of the patient's wishes. The supportive parents of the college student may create conflict with the boyfriend, but the parents' ongoing friendship and shared values will assist in reducing conflict. The male admitted for bypass surgery, although in a same-sex relationship, has clearly identified whom he wants to make health care decisions for him. The elderly female may have conflict with her son; however, she is capable of making her own decisions and has a written advance directive to support her decisions.

20. The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy? a. View the family as guests on the unit. b. Acknowledge family emotions. c. Learn as much as you can about family structure and function. d. Use a trained interpreter if the family does not speak English.

b. Acknowledge family emotions. ANS: B The VALUE mnemonic includes the following: V—Value what the family tells you. A—Acknowledge family emotions. L—Listen to the family members. U—Understand the patient as a person. E—Elicit (ask) questions of family members.

11. The family members of a critically ill patient bring a copy of the patient's living will to the hospital, which identifies the patient's wishes regarding health care. You discuss contents of the living will with the patient's physician. This is an example of implementation of which of the AACN Standards of Professional Performance? a. Acquires and maintains current knowledge of practice b. Acts ethically on the behalf of the patient and family c. Considers factors related to safe patient care d. Uses clinical inquiry and integrates research findings in practice

b. Acts ethically on the behalf of the patient and family ANS: B Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The example does not relate to acquiring knowledge, promoting patient safety, or using research in practice.

25. The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which prescription by the provider should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam. c. Obtain stat portable chest x-ray. d. Administer phenytoin.

b. Administer lorazepam. ANS: B The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticus. Phenytoin is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

27. The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Administer over 20 to 30 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

b. Administer over 20 to 30 minutes. ANS: B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Phenytoin should be administered over 20 to 30 minutes. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario.

26. The provider prescribes fosphenytoin, 1.5 g intravenous (IV) loading dose, for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer the drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

b. Administer the drug over 10 minutes. ANS: B The nurse can administer the medication over 10 minutes as prescribed (100 to 150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose prescribed is appropriate for the patient's weight. Fosphenytoin does not have to be administered with normal saline or via a central line.

15. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the provider of the patient's blood pressure.

b. Assess for a kinked urinary catheter and assess for bowel impaction. ANS: B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system, can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distension. Other causes that should be ruled out before pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow, deep breaths will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the provider.

8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours. b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. d. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place. e. Maintain NPO status for 12 hours.

b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. ANS: B, C The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity. NPO status does not need to be maintained after the patient is fully alert.

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion

b. Assessment of respiratory rate and effort Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

b. Assist the patient onto the bedside commode every 2 hours. Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection and skin breakdown.

25. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second-degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions

b. Atrial fibrillation or flutter ANS: B Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

16. The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures? a. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. b. Contact the hospital's interpreter service for someone to translate. c. Get in touch with one of the residents who you know is fluent in the native language and ask him if he can come up to the unit. d. Use the patient's 8-year-old child who is fluent in both English and the native language to translate for you.

b. Contact the hospital's interpreter service for someone to translate. ANS: B The best approach when communicating with someone whose primary language is not English is to use the interpreter services of the agency. These individuals are trained and knowledgeable. If the nurse conducted a search on the computer, he or she would not know if the information retrieved was valid, nor would the nurse know if the patient or family can read in their native language. Although one of the residents might be fluent in the language, you do not know his or her abilities to translate. In addition, the resident's availability is likely to be limited. Although the child might be able to translate, the nurse cannot ensure that the child is translating health care concepts correctly.

10. You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with report. Which information do you convey regarding background? a. Urine output of 40 mL/2 hours b. Current vital signs and history of aortic aneurysm repair 4 hours ago c. A statement that the patient is possibly hypovolemic d. A request for IV fluids

b. Current vital signs and history of aortic aneurysm repair 4 hours ago ANS: B The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurse's assessment, and the suggestion for fluids is the recommendation.

17. Family assessment can be challenging, and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift? a. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed. b. Develop a standardized reporting form for family information that is incorporated into the patient's medical record and updated as needed. c. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues. d. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.

b. Develop a standardized reporting form for family information that is incorporated into the patient's medical record and updated as needed. ANS: B A standardized method for gathering data about family structure and function and recording it in an official document is the best approach. This strategy ensures that data are collected and kept in the medical record. Data are also easily retrievable by anyone who needs to know this information. Informal documentation is often kept to assist in follow-up and change-of-shift reporting; however, this strategy is not recommended, as data collected are likely to vary and not be part of a permanent record. Although the charge nurse often has some information regarding families, the primary responsibility for assessment and follow-up belongs to the bedside nurse. Family information should be shared at change of shift using a standardized format, not "try to remember to discuss...."

3. The nurse utilizes which of the following strategies when encountering an ethical dilemma in practice? (Select all that apply.) a. Change-of-shift report updates b. Ethics consultation services c. Formal multiprofessional ethics committees d. Pastoral care services e. Social work consultation

b. Ethics consultation services c. Formal multiprofessional ethics committees ANS: B, C Formal mechanisms such as multiprofessional ethics committees or referral services are strategies to address ethical issues. Nurse-to-nurse communication can help share information from shift to shift, but it is not the best way to address ethical issues. Pastoral care representatives may serve on an ethics committee; however, their primary role is to support the spiritual needs of the patient and family. A social worker may be very beneficial, but is not at the level of a multiprofessional committee.

8. Which intervention is appropriate to assist the patient in coping with admission to the critical care unit? a. Allowing unrestricted visiting by several family members at one time b. Explaining all procedures in easy-to-understand terms c. Providing back massage and mouth care d. Turning down the alarm volume on the cardiac monitor

b. Explaining all procedures in easy-to-understand terms ANS: B Communication and explanations of procedures are priority interventions to help patients cope with admission. Comfort is an important intervention but not the priority. Noise control is an important intervention but not the priority. Open visitation is recommended; however, the number of family members may need to be limited to promote rest and sleep.

7. Which nursing interventions would best support the family of a critically ill patient? a. Encourage family members to stay all night in case the patient needs them. b. Give a condition update each morning and whenever changes occur. c. Limit visitation from children into the critical care unit. d. Provide beverages and snacks in the waiting room.

b. Give a condition update each morning and whenever changes occur. ANS: B The need for information is one of the highest identified by family members of critically ill patients. A planned condition update helps the family know what to expect. New room designs provide space for family members to spend the night if desired; however, if the patient is stable, family members should be encouraged to sleep at home to ensure that they are well rested and can support the patient. Restriction of children in the critical care unit is not supported by research evidence. Child visitation should be individualized based on the needs and wishes of the patient and family. Beverages and snacks are important but not as important as information.

23. The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the provider of the BP. d. Begin weaning the infusion.

b. Increase the dose by 2.5 mg/hr. ANS: B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient's blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the provider of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.

Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side.

b. Inspect the oral mucosa and teeth. Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

b. Instruct the patient how to self-catheterize. Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

19. A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option

b. Left ventricular assist device (LVAD) ANS: B LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.

18. The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.

b. Maintain proper head and neck alignment. ANS: B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient's airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

19. The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.

b. Monitor blood pressure. ANS: B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority. Hand washing is important for all patients. There is no indication the patient has temperature alterations. Padding bony prominences may or may not be needed.

9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. New murmur c. S1 heart sound d. S3 heart sound

b. New murmur ANS: B The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.

Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use? a. Avoid use of sedatives. b. Provide a quiet environment. c. Check pupil reaction to light every 4 hours. d. Provide range-of-motion exercises several times daily.

b. Provide a quiet environment. In patients with tetanus, painful seizures can be precipitated by jarring, loud noises, or bright lights, so the nurse will minimize noise and avoid shining light into the patient's eyes. Range-of-motion exercises may also stimulate the patient and cause seizures. Although the patient has a history of injectable drug use, sedative medications will be needed to decrease spasms.

1. Family members have a need for information. Which interventions best assist in meeting this need? a. Handing family members a pamphlet that explains all of the critical care equipment b. Providing a daily update of the patient's progress and facilitating communication with the intensivist c. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist d. Writing down a list of all new medications and doses and giving the list to family members during visitation

b. Providing a daily update of the patient's progress and facilitating communication with the intensivist ANS: B The nurse can give a status report related to the patient's condition and current treatment plan as well as ensure that the family has daily meeting time with the intensivist for an update on diagnoses, prognoses, and the like. Pamphlets are helpful; however, the nurse should also explain the equipment that is at this patient's bedside and not assume that everyone can read and understand written material. Limiting the information to that provided by the physician is unnecessary and will not meet the family's information needs. Most family members are concerned about the patient's general condition and treatment plan. They do not want or need a detailed list of medications, doses, or other treatments.

A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which action by the nurse is best? a. Clarify that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patient's comments. d. Reassure the patient about the competence of the nursing staff.

b. Request that the patient provide input for the plan of care. The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? History Physical Assessment Physical/Occupational Therapy Well controlled type 2 diabetes for 10 years Married 45 years; spouse has heart failure and chronic obstructive pulmonary disease Oriented to time, place, person Speech clear Minimal left leg weakness Uses cane with walking Spouse does household cleaning and cooking and assists patient with bathing and dressing a. Impaired transfer ability b. Risk for caregiver role strain c. Ineffective health maintenance d. Risk for unstable blood glucose level

b. Risk for caregiver role strain The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

b. The patient has difficulty speaking. Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient's triceps reflexes are absent. b. The patient is continuously drooling saliva. c. The patient complains of severe pain in the feet. d. The patient's blood pressure (BP) is 150/82 mm Hg.

b. The patient is continuously drooling saliva. Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

b. The patient's blood pressure (BP) is 90/50 mm Hg. To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

18. Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test

b. Transesophageal echocardiogram ANS: B In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns. The other tests do not alter the gag reflex.

15. You work in an intermediate care unit and have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force and that your ideas will be rejected by others. This situation is an example of a. a barrier to handoff communication. b. a work environment that is unhealthy. c. ineffective decision making. d. nursing practice that is not evidence-based.

b. a work environment that is unhealthy. ANS: B These are examples of an unhealthy work environment. A healthy work environment values communication, collaboration, and effective decision making. It also has authentic leadership. It is not an example of handoff communication, which is communication that occurs to transition patient care from one staff member to another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidence-based practice, but your influence in the unit is limited by the unhealthy work environment.

Before administering botulinum antitoxin to a patient in the emergency department, it is most important for the nurse to a. obtain the patient's temperature. b. administer an intradermal test dose. c. document the neurologic symptoms. d. ask the patient about an allergy to eggs.

b. administer an intradermal test dose. To assess for possible allergic reactions, an intradermal test dose of the antitoxin should be administered. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin.

A construction worker arrives at an urgent care center with a deep puncture wound after an old nail penetrated his boot.. The patient reports having had a tetanus booster 6 years ago. The nurse will anticipate a. IV infusion of tetanus immune globulin (TIG). b. administration of the tetanus-diphtheria (Td) booster. c. intradermal injection of an immune globulin test dose. d. initiation of the tetanus-diphtheria immunization series.

b. administration of the tetanus-diphtheria (Td) booster. If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.

10. The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential organ donor. To proceed with donation, the nurse understands that a. a signed donor card mandates that organs be retrieved in the event of brain death. b. after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room. c. the health care proxy does not need to give consent for the retrieval of organs. d. once a patient has been established as brain dead, life support is withdrawn and organs are retrieved.

b. after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room. ANS: B After brain death has been determined, the organs must be perfused to maintain viability. Therefore, the patient remains on life support even though he or she is legally dead. A signed donor card indicates the individual's wishes; however, most organ procurement agencies require family consent even if a donor card has been signed. In most states, the health care surrogate or proxy is required to give consent for organ donation. After brain death has been determined, perfusion and oxygenation of organs are maintained until organs can be removed in the operating room.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

b. aspirin (Ecotrin). After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

26. An essential aspect of teaching that may prevent recurrence of heart failure is a. notifying the provider if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

b. compliance with diuretic therapy. ANS: B Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure. Notifying the provider of a weight gain and assessing a pulse are important self-care activities but will not prevent a recurrence of heart failure. Nitroglycerin is used for coronary artery disease.

3. The first critical care units were (Select all that apply.) a. burn units. b. coronary care units. c. recovery rooms. d. neonatal intensive care units. e. high-risk OB units.

b. coronary care units. c. recovery rooms. ANS: B, C Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn, neonatal intensive care, and high-risk OB units were established as specialty units evolved.

1. Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.) a. asking the family to leave during the morning bath to promote the patient's privacy. b. encouraging family members to make notes of questions they have for the physician during family rounds. c. if possible, providing continuity of nursing care. d. providing a daily update of the patient's condition to the family spokesperson. e. ensuring that a waiting room stocked with snacks is nearby.

b. encouraging family members to make notes of questions they have for the physician during family rounds. c. if possible, providing continuity of nursing care. d. providing a daily update of the patient's condition to the family spokesperson. ANS: B, C, D Encouraging families to formulate questions assists in family care. Continuity of nursing care with consistent staff members assists in reducing stress. Communicating daily updates of the patient's condition meets the family's need for information. Family members often want to assist with simple activities of patient care, so limiting participation is the exception to this list. A comfortable waiting room is necessary; however, it may or may not impact the family's stress level.

The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury.

b. function of both arms should be retained. The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

5. The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to respond to medical treatment. The intensivist in charge of the patient conducts a conference to explain that treatment options have been exhausted and to suggest that the patient be given a "do not resuscitate" status. This scenario illustrates the concept of a. brain death. b. futility. c. incompetence. d. life-prolonging procedures.

b. futility. ANS: B This is the definition of futility. Brain death is cessation of brain function and is not described in this scenario. Incompetence (in this chapter) is when a patient is unable to make decisions regarding health care treatment. A life-prolonging procedure is one that sustains, restores, or supplants a spontaneous vital function.

12. The nurse is caring for a critically ill patient on mechanical ventilation. The physician identifies the need for a bronchoscopy, which requires informed consent. For the physician to obtain consent from the patient, the patient must be able to a. be weaned from mechanical ventilation. b. have knowledge and competence to make the decision. c. nod his head that it is okay to proceed. d. read and write in English.

b. have knowledge and competence to make the decision. ANS: B Informed consent requires that a person know what is to be done and have the competence to make an informed decision. Most critically ill patients do not have this capacity; however, an assessment should be made to determine the patient's capacity. Some patients on mechanical ventilation are able to give written consent. Reading and writing in English are not requirements for informed consent.

When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair.

b. push a manual wheelchair on a flat surface. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

20. The provider has opted to treat a patient with a complete spinal cord injury with Solumedrol. The provider orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hr for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg

c. 10,794 mg ANS: C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg × 70 kg) + (5.4 mg × 70 kg) × 23 hours = 10,794 mg.

22. The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first? a. Blood cultures (2 specimens) for temperature >101°F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours

c. 500 mL albumin infusion intravenously ANS: C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg

c. 90 mm Hg ANS: C CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.

3. Which statement regarding ethical concepts is true? a. A living will is the same as a health care proxy. b. A signed donor card ensures that organ donation will occur in the event of brain death. c. A surrogate is a competent adult designated by a person to make health care decisions in the event the person is incapacitated. d. A persistent vegetative state is the same as brain death in most states.

c. A surrogate is a competent adult designated by a person to make health care decisions in the event the person is incapacitated. ANS: C A surrogate is a competent adult designated by a person to make health care decisions if that person becomes incapacitated. A living will is a witnessed document that states a person's wishes regarding life-prolonging procedures, whereas a health care proxy is a person authorized by state statute to make health care decisions. In many states, consent by family members or health care proxy is required for organ donation even if an individual has a signed donor card. A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact; brain death is cessation of brain function.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

c. Administer the prescribed short-acting insulin. Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed analgesic. c. Assess the blood pressure (BP). d. Notify the health care provider.

c. Assess the blood pressure (BP). The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.

c. Assist in planning a prescribed bowel program. Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

c. Assist the patient to eat with the right hand. Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

2. A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for the nurse to seek? a. ACNPC-AG b. CNML c. CCRN d. PCCN

c. CCRN ANS: C The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The ACNPC-AG certification is for acute care nurse practitioners. The CNML is for critical care nurse managers or leaders. The PCCN certification is for staff nurses working in progressive care, intermediate care, or step-down unit settings.

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.

c. Check the respiratory rate and effort. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

5. The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and that they have some questions they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange a meeting with the family at 4:00 PM. Which competency of critical care nursing does this represent? a. Advocacy and moral agency in solving ethical issues b. Clinical judgment and clinical reasoning skills c. Collaboration with patients, families, and team members d. Facilitation of learning for patients, families, and team members

c. Collaboration with patients, families, and team members ANS: C Although one might consider that all of these competencies are being addressed, communication and collaboration with the family and physician best exemplify the competency of collaboration.

24. The nurse is preparing to administer a routine dose of phenytoin. The provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the provider. d. Assess cardiac rhythm.

c. Contact the provider. ANS: C The ordered dose is an inappropriate maintenance dose. The nurse should contact the provider. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

c. Death of cardiac muscle from lack of oxygen (tissue necrosis). ANS: C Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches. Coronary artery spasms and transient oxygen imbalance are not related to a myocardial infarction. Ischemia, if not reversed, will eventually lead to tissue necrosis.

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider? a. Back pain that increases with coughing b. Depression about the diagnosis of a tumor c. Decreasing sensation and ability to move the legs d. Anxiety about scheduled surgery to remove the tumor

c. Decreasing sensation and ability to move the legs Decreasing sensation and leg movement indicates spinal cord compression, an emergency that will require rapid action (such as surgery) to prevent paralysis. The other findings will also require nursing action but are not emergencies.

19. Open visitation policies are expected by many professional organizations. Which statement reflects adherence to current recommendations? a. Allow animals on the unit; however, these can only be "therapy" animals through the hospital's pet therapy program. b. Allow family visitation throughout the day except at change of shift and during rounds. c. Determine, in collaboration with the patient and family, who can visit and when. Facilitate open visitation policies. d. Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour.

c. Determine, in collaboration with the patient and family, who can visit and when. Facilitate open visitation policies. ANS: C Open visitation is considered best practice. Limiting visitation is not supported by research. Facilities should develop visitation schedules in collaboration with the patient and family. Animals do not need to be limited to therapy animals. Many patients benefit from the presence of personal pets brought to the unit according to hospital policy. Although many units restrict visitation during report and rounds for confidentiality, family-centered facilities will encourage family participation during report and rounds. Children should not be banned arbitrarily from the unit or have hours limited.

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

c. Disabled family coping related to inadequate understanding by patient's spouse The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.

18. The nurse knows that which of the following statements about organ donation is true? a. Anyone who is comfortable approaching the family should discuss the option of organ donation. b. Brain death determination is required before organs can be retrieved for transplant. c. Donation of selected organs after cardiac death is ethically acceptable. d. Family members should consider the withdrawal of life support so that the patient can become an organ donor.

c. Donation of selected organs after cardiac death is ethically acceptable. ANS: C Donation of selected organs after cardiac death is ethically and legally appropriate. Specific policies and procedures for donation after cardiac death facilitate this procedure. Only designated requesters who are knowledgeable and trained in organ donation should approach the family to discuss donation. Organs can be retrieved not only after brain death but also after cardiac death. The decision to withdraw life support should be made separately from the decision to donate organs.

2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting

c. Dyspnea and crackles ANS: C In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

7. A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study

c. Echocardiogram ANS: C Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers. The ECG provides information related to the heart's electrical activity. A cardiac catheterization directly visualizes coronary arteries. Electrophysiology studies are done to evaluate dysrhythmias.

14. Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach? a. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. b. Explain the unit routine. c. Explain procedures before and while you are doing them. d. Suction Mr. J.'s endotracheal tube immediately when he starts to cough.

c. Explain procedures before and while you are doing them. ANS: C Anxiety is reduced when procedures are explained before completing them and when the nurse continues to talk to the patient during them. Limiting visitation has not been demonstrated by research to benefit patients. Explaining the unit routine is important but is not as specific to the patient as explaining a procedure right before doing it. Providing physical care is vital to critically ill patients, but may or may not reduce anxiety.

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

c. Explain that the aspirin is ordered to decrease stroke risk. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a. Hyperactive reflex activity below the level of injury b. Involuntary, spastic movements of the arms and legs c. Hypotension, bradycardia, and warm, pink extremities d. Lack of sensation or movement below the level of injury

c. Hypotension, bradycardia, and warm, pink extremities Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.

3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low.

c. ICP is high; CPP is normal. ANS: C The ICP is above the normal level of 0 to 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.

5. Family assessment is essential to meet family needs. Which of the following must be assessed first to assist the nurse in providing family-centered care? a. Assessment of patient and family's developmental stages and needs b. Description of the patient's home environment c. Identification of immediate family, extended family, and decision makers d. Observation and assessment of how family members function with each other

c. Identification of immediate family, extended family, and decision makers ANS: C Assessment of the family structure is the first step and is essential before specific interventions can be designed. It identifies immediate family, extended family, and decision makers in the family. Structural assessment also includes ethnicity and religion. The developmental assessment is done after the structural assessment and includes the developmental stages of the patient and family. Functional assessment is also important to assess how family members function with each other; however, it is not done first. Assessment of the home environment is important when identifying discharge planning needs.

32. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5°F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bed rest at all times.

c. Implement seizure precautions. ANS: C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation, such as photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bed rest are all appropriate nursing interventions but are not the priorities in this scenario.

8. The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

c. Increased cerebral blood volume due to vessel dilation ANS: C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.

A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

c. Multiple options are available to maintain sexuality after spinal cord injury. Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

c. Myocardial remodeling ANS: C Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

6. A patient is admitted with angina. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta blockers d. Statins, bile acid, and nicotinic acid

c. Nitroglycerin, oxygen, and beta blockers ANS: C Conservative intervention for the patient experiencing angina includes nitrates, beta blockers, and oxygen.

4. Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. Non-Q wave d. Q wave e. Frequent PVCs

c. Non-Q wave d. Q wave ANS: C, D AMI can be classified as Q wave or non-Q wave.

5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery

c. Partial occlusion of a coronary artery with a thrombus ANS: C In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy. Complete occlusion is associated with a myocardial infarction. A fatty streak is present in all vessels affected by coronary artery disease. Vasospasm leads to Prinzmetal's angina.

5. 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? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.

c. Place a nasal drip pad under the nose. ANS: C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

c. Place objects needed on the patient's left side. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to look at the right leg to verify its position

c. Positioning the patient's left leg when turning the patient The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost on the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement

c. Radiofrequency catheter ablation ANS: C Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway. A cardioverter-defibrillator is used on patients with potentially lethal rhythms such as ventricular fibrillation. A pacemaker is not used for this condition.

1. The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device "prn" c. Recording ICP as a "mean" value d. Use of a pressurized flush system e. Zero referencing the transducer system

c. Recording ICP as a "mean" value e. Zero referencing the transducer system ANS: C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Monro. Manually flushing the device may result in an increase in ICP.

11. A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and aVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non-Q wave MI c. Silent myocardial infarction d. Unstable angina

c. Silent myocardial infarction ANS: C Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. These can occur with no presenting signs or symptoms; however, the patient's troponin levels and ECG are consistent with an MI. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients. The patient does not fit the criteria for hypokalemia, a non-Q wave MI, or unstable angina.

3. The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathing the patient? a. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure. b. Because the patient is unconscious, complete care as quickly and quietly as possible. c. Tell the patient the day and time, and that you are providing a bath. Reassure the patient that you are there. d. Turn the television on to the evening news so that you and the patient can be updated to current events.

c. Tell the patient the day and time, and that you are providing a bath. Reassure the patient that you are there. ANS: C Although unconscious, many patients can hear, understand, and respond to stimuli. Therefore, it is important to converse with the patient and reorient her to the environment. Some, but not all, family members may want to get involved in direct care; it is not known if this individual is a willing participant, and talking about who's who in the family is inappropriate while providing direct care to the patient. Although the patient is unconscious, communication and simple conversations remain important interventions. Use of the television to provide sensory input that the patient regularly enjoys is a nursing intervention, but turning on the news for the sake of the nurse is not appropriate.

14. When addressing an ethical dilemma, contextual, physiological, and personal factors of the situation must be considered. Which of the following is an example of a personal factor? a. The hospital has a policy that everyone must have an advance directive on the chart. b. The patient has lost 20 pounds in the past month and is fatigued all the time. c. The patient has told you what quality of life means and his or her wishes. d. The physician considers care to be futile in a given situation.

c. The patient has told you what quality of life means and his or her wishes. ANS: C Personal factors include competence, stated wishes, goals and hopes, definition of quality of life, and family relationships. Hospital policy is a contextual factor. Weight loss and fatigue are physiological factors. The physician's belief is a contextual factor.

10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.

c. The patient is exhibiting purposeful movement. ANS: C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

c. The patient reports that symptoms began with a severe headache. A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

c. The patient's usual blood pressure (BP) is 170/94 mm Hg. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension

5. Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.) a. The nephrology consultant physician is making rounds and asks you for an update on the patient's status and to assist in placing a central line for hemodialysis. b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurses' station. c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. You and the oncoming nurse conduct a standardized report at the patient's bedside and review key assessment findings. e. The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse.

c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. You and the oncoming nurse conduct a standardized report at the patient's bedside and review key assessment findings. ANS: C, D A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurses' station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse. Likewise, noise in the nurses' station can cause distractions that can impair concentration and listening. Giving medications at the same time as handoff report could lead to serious errors both in medication administration and in the report itself.

11. Which intervention about visitation in the critical care unit is true? a. The majority of critical care nurses implement restricted visiting hours to allow the patient to rest. b. Children should never be permitted to visit a critically ill family member. c. Visitation that is individualized to the needs of patients and family members is ideal. d. Visiting hours should always be unrestricted.

c. Visitation that is individualized to the needs of patients and family members is ideal. ANS: C Visiting should be based on the needs of patients and their families. There may be times when visiting needs to be limited (e.g., to allow the patient to rest); however, it is important to individualize visitation. Sometimes it is appropriate for children to visit; research has not found child visitation to be harmful to either the patient or the child. Visiting should be adjusted to patient needs.

20. The provider prescribes a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. dopamine. b. dobutamine. c. adenosine. d. atropine.

c. adenosine. ANS: C If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed. Dopamine and atropine are not used.

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will a. assess whether the patient is doing daily facial exercises. b. question whether the patient is using an eye shield at night. c. ask the patient about social activities with family and friends. d. remind the patient to chew on the unaffected side of the mouth.

c. ask the patient about social activities with family and friends. Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

c. assist the patient into a chair. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted.

15. The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.

c. contact the physician immediately and begin prepping the patient for surgery. ANS: C These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.

A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop because the patient is able to perform activities independently. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and encourage that participation.

c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

6. The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. Several weeks later, the patient is still ventilator dependent and unresponsive to stimulation but occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and is not expected to recover consciousness. The nurse recognizes that this patient is a. an organ donor. b. brain dead. c. in a persistent vegetative state. d. terminally ill.

c. in a persistent vegetative state. ANS: C A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact purposefully with the environment. The patient is not brain dead, as evidenced by occasionally taking a spontaneous breath. Because the patient is not brain dead, he or she cannot be an organ donor at this time. Treatment of this condition may be considered futile; however, this condition would not be defined as terminally ill.

9. The nurse is caring for a patient who is not responding to medical treatment. The intensivist holds a conference with the family, and a decision is made to withdraw life support. The nurse's religious beliefs are not in agreement with the withdrawal of life support. However, the nurse assists with the process to avoid confronting the charge nurse. Afterward the nurse feels guilty for "killing the patient." This scenario is likely to cause a. abandonment. b. family stress. c. moral distress. d. negligence.

c. moral distress. ANS: C Moral distress occurs when the nurse acts in a manner contrary to personal or professional values. Abandonment is defined as the unilateral severance of a professional relationship while a patient is still in need of health care. Family stress would not be impacted in this situation if the nurse responded appropriately during the procedure. Negligence is failure to act according to the standard of care.

7. A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit the patient's response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of a. beneficence. b. fidelity. c. nonmaleficence. d. veracity.

c. nonmaleficence. ANS: C Nonmaleficence means not to intentionally harm others. The nurse does need to determine the patient's response to painful stimulation but does so in a way that is ethical. Beneficence demonstrates actions intended to benefit the patients or others. Fidelity is the moral duty to be faithful to the commitments that one makes to others. Veracity is the obligation to tell the truth.

A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to carry out is a. determining level of consciousness. b. checking strength of the extremities. c. observing respiratory rate and effort. d. monitoring the cardiac rate and rhythm.

c. observing respiratory rate and effort. The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

c. oral low-dose aspirin therapy. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

14. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg ANS: C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35 to 45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.

1. Ideally, an advance directive should be developed by the a. family if the patient is in critical condition. b. patient as part of the hospital admission process. c. patient before hospitalization. d. patient's health care surrogate.

c. patient before hospitalization. ANS: C Advance directives should be made and signed while a person is in good health and in a state of mind to make decisions about what should happen if he or she becomes incapacitated (e.g., during a critical illness). Families help to make decisions based on written advance directives, but families are not responsible for developing them for the patient. Developing advance directives during the admission process is not feasible, and the patient may not be capable of making an advance directive. The surrogate or proxy is one who has been already designated by a person to make health care decisions based on written advance directives.

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patient's mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.

c. push upward on the epigastric area as the patient coughs. Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.

13. Comparing the patient's current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next provider when the patient is transferred within an organization or to another setting are strategies to: a. improve accuracy of patient identification. b. prevent errors related to look-alike and sound-alike medications. c. reconcile medications across the continuum of care. d. reduce harms associated with the administration of anticoagulants.

c. reconcile medications across the continuum of care. ANS: C These are steps recommended in the National Patient Safety Goals to reconcile medications across the continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal. Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, but is not related to transferring the patient between settings. Reducing harms associated with the administration of anticoagulants is another National Patient Safety Goal.

17. A nurse who plans care based on the patient's gender, ethnicity, spirituality, and lifestyle is said to a. be a moral advocate. b. facilitate learning. c. respond to diversity. d. use clinical judgment.

c. respond to diversity. ANS: C Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning. Clinical judgment uses other factors as well.

8. The vision of the American Association of Critical-Care Nurses is a health care system driven by a. a healthy work environment. b. care from a multiprofessional team under the direction of a critical care physician. c. the needs of critically ill patients and families. d. respectful, healing, and humane environments.

c. the needs of critically ill patients and families. ANS: C The AACN vision is a health care system driven by the needs of critically ill patients and families where critical care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work environment as well as respectful and healing environments, but that is not the organization's vision. The Society of Critical Care Medicine (SCCM) promotes care from a multiprofessional team under the direction of a critical care physician.

4. The synergy model of practice focuses on a. allowing unrestricted visiting for the patient 24 hours a day. b. holistic and alternative therapies. c. the needs of patients and their families, which drive nursing competency. d. patients' needs for energy and support.

c. the needs of patients and their families, which drive nursing competency. ANS: C The synergy model of practice states that the needs of patients and families influence and drive competencies of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patient's and family's needs and the application of alternative therapies if desired by the patient, but that is not the primary focus of the model.

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

c. visual deficits. Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? a. "You may be able to prevent Bell's palsy by doing facial exercises regularly." b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "Call the doctor if you experience pain or develop herpes lesions near the ear."

d. "Call the doctor if you experience pain or develop herpes lesions near the ear." Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy

27. A patient is having an emergent coronary intervention, and the nurse is starting an infusion of abciximab. The patient asks what the purpose of this drug is. What response by the nurse is best? a. "This will help prevent chest pain until the intervention is complete." b. "This medication dries oral and respiratory secretions during the procedure." c. "This is a mild sedative and amnesic agent, so you'll be very relaxed." d. "This drug helps prevent blood clotting and is often used for this procedure."

d. "This drug helps prevent blood clotting and is often used for this procedure." ANS: D Abciximab is a glycoprotein IIb/IIIc inhibitor and antiplatelet agent. It is used to prevent clotting in acute coronary syndromes and coronary intervention patients. The other statements are inaccurate.

30. After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F

d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F ANS: D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104°F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis, and droplet precautions are appropriate for a patient with bacterial meningitis.

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

11. The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.

d. Apply a small nasal drip pad. ANS: D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.

7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg

d. CVP of 2 mm Hg ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum, indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.

16. The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patient's general orientation. c. Determine the patient's drug allergies. d. Determine the time of symptom onset.

d. Determine the time of symptom onset. ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

d. Difficulty comprehending instructions Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke

13. The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows a potentially lethal rhythm. The patient has no pulse. The patient does not have a "do not resuscitate" order written on the chart. What is the appropriate nursing action? a. Contact the attending physician immediately to determine if CPR should be initiated. b. Contact the family immediately to determine if they want CPR to be started. c. Give emergency medications but withhold intubation. d. Initiate CPR and call a code.

d. Initiate CPR and call a code. ANS: D Because no orders have been written, it is imperative that a code be called. In this example, decisions regarding resuscitation status should be determined as soon as possible before a code event. The physician and family should be contacted immediately to determine treatment options, but CPR is not withheld. It is not appropriate to conduct a "partial" code by giving medications only.

23. Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery

d. Left main coronary artery ANS: D Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention. Lesions in the other locations are candidates for this procedure.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan

d. Noncontrast computed tomography (CT) scan Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the provider immediately.

d. Notify the provider immediately. ANS: D These are classic symptoms of epidural hematomas: injury, lucid period, and progressive deterioration. The provider must be notified of this neurological emergency so that appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient, and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the provider is a priority given the severity in change of neurological status.

6. The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical care nursing practice? a. Evidence-based practice b. Healthy work environment c. National Patient Safety Goals d. Nursing process

d. Nursing process ANS: D The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care, implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not included in its standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN standards.

Which of these nursing actions for a 64-year-old patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distention q2hr d. Passive range of motion to extremities q4hr

d. Passive range of motion to extremities q4hr Assisting a patient with movement is included in UAP education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.

17. The critical care nurse wants a better understanding of when to initiate an ethics consult. After attending an educational program, the nurse understands that the following situation would require an ethics consultation: a. Conflict has occurred between the physician and family regarding treatment decisions. A family conference is held, and the family and physician agree to a treatment plan that includes aggressive treatment for 24 hours followed by reevaluation. b. Family members disagree as to a patient's course of treatment. The patient has designated a health care proxy and has a written advance directive. c. Patient postoperative coronary artery bypass surgery who sustained a cardiopulmonary arrest in the operating room. He was successfully resuscitated, but now is not responding to treatment. He has a written advance directive, and his wife is present. d. Patient with multiple trauma and is not responding

d. Patient with multiple trauma and is not responding to treatment. No family members are known, and the health care team is debating if care is futile. ANS: D In the case of a seriously ill patient who is incapacitated and does not have a surrogate, an ethics consultation is warranted. While care does not have to be provided in the case of futility, disagreements may lead to the need for a consult to resolve the dilemma. The conflict has been resolved in the case of the family and physician agreeing on a course of treatment for 24 hours followed by reevaluation. Although family members disagree, if a patient has a written advance directive and a designated health care proxy, an ethics consultation is unwarranted; the patient's wishes are clearly known. The cardiac surgery patient has a written directive to guide his treatment.

4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient's head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.

d. Provide rest periods between nursing interventions. ANS: D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient's plan of care; however, spacing out interventions is the priority.

12. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.

d. Reduce ambient room temperature and administer antipyretics. ANS: D In this scenario, the patient's temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

d. Risk for aspiration related to inability to protect airway Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

15. The intensive care nurse is working on a committee to reduce noise in the unit. Which recommendation should the nurse propose first? a. Change telephones to blinking lights instead of audible ringtones. b. Invest in call lights that page the nursing staff instead of beeping. c. Recommend that nurses turn off cardiac monitors on stable patients. d. Soundproof the pneumatic tube system.

d. Soundproof the pneumatic tube system. ANS: D The pneumatic tube system is extremely loud at 88dB[A] and should be the first proposal as it will have the biggest impact on noise on the unit. Call light systems typically ring at the 48-63 dB[A] range and are also a significant cause of noise, but not as much as the pneumatic tube system. Telephones are also noisy, ringing at 60-67 dB[A]. Nurses should never shut off monitor alarms as this is a patient safety issue.

8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins

d. Statins ANS: D The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs such as bile acid resins and nicotinic acid. Nitroglycerin is used for chest pain.

21. Changing visitation policies can be challenging. The nurse manager recognizes which of the following as an effective strategy for promoting changes in practice? a. Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked to read one research article about visitation. b. Discuss the pros and cons of open visitation at the next staff meeting. c. Invite the nurses with the most experience to develop a revised policy. d. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation.

d. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation. ANS: D Changes in policy are most effective through willing champions as part of a unit-based, staff-led practice council. Discussion of evidence-based findings is important, but it is not logical to expect every nurse to read a research article and share findings. Discussion of pros and cons at a staff meeting is likely to be prolonged and based on opinion rather than evidence. Nurses with the most experience are not necessarily the ones to develop a new policy. They may be the least likely to change; therefore, it is important to solicit volunteers from all staff members, not just the experienced ones.

8. Which of the following organizations requires a mechanism for addressing ethical issues? a. American Association of Critical-Care Nurses b. American Hospital Association c. Society of Critical Care Medicine d. The Joint Commission

d. The Joint Commission ANS: D The Joint Commission requires that a formal mechanism be in place to address patients' ethical concerns. The other organizations do not address formal ethics committees.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

d. The patient has atrial fibrillation and takes warfarin (Coumadin). The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

16. Which of the following statements describes the core concept of the synergy model of practice? a. All nurses must be certified in order to have the synergy model implemented. b. Family members must be included in daily interdisciplinary rounds. c. Nurses and physicians must work collaboratively and synergistically to influence care. d. Unique needs of patients and their families influence nursing competencies.

d. Unique needs of patients and their families influence nursing competencies. ANS: D The synergy model of practice is care based on the unique needs and characteristics of the patient and family members. Although critical care certification is based on the synergy model, the model does not specifically address certification. Inclusion of family members into the daily rounds is an example of implementation of the synergy model. With the focus on patients and family members with nurse interaction, the synergy model does not address physician collaboration.

4. Which of the following statements about resuscitation is true? a. Family members should never be present during resuscitation. b. It is not necessary for a physician to write "do not resuscitate" orders in the chart if a patient has a health care surrogate. c. "Slow codes" are ethical and should be considered in futile situations if advanced directives are unavailable. d. Withholding "extraordinary" resuscitation is legal and ethical if specified in advance directives and physician orders.

d. Withholding "extraordinary" resuscitation is legal and ethical if specified in advance directives and physician orders. ANS: D Withholding resuscitation and other care is legal and ethical if based on the patient's wishes. Formal orders should be written that specify what is to be done if a patient suffers a cardiopulmonary arrest. Family presence during resuscitation and invasive procedures should be encouraged. A written order for "do not resuscitate" must be documented in the medical record. The decision to write the order is made in collaboration with the health care surrogate. "Slow codes" sometimes occur in the clinical setting while attempts are made to contact the health care surrogate or proxy; however, they are neither legal nor ethical. Specific written orders determine what is to be done for resuscitation efforts.

A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about a. intubation and mechanical ventilation. b. administration of corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. infusion of immunoglobulin (Sandoglobulin).

d. infusion of immunoglobulin (Sandoglobulin). Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

15. A specific request made by a competent person that directs medical care related to life-prolonging procedures in the event that person loses capacity to make decisions is called a a. "do not resuscitate" order. b. health care proxy. c. informed consent. d. living will.

d. living will. ANS: D A living will is a formal advance directive that directs medical care related to life-prolonging procedures when a person does not have the capacity to make decisions regarding health care and treatment. A "do not resuscitate" order is a legal medical order prohibiting resuscitation measures in the event of clinical death. A health care proxy is an individual designated by the person to make decisions if incapacitated. Informed consent involves decisions regarding treatments and procedures following explanation of risks and benefits.

9. The most important outcome of effective communication is to a. demonstrate caring practices to family members. b. ensure that patient teaching is done. c. meet the diversity needs of patients. d. reduce patient errors.

d. reduce patient errors. ANS: D Many errors are directly attributed to faulty communication. Effective communication has been identified as an essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication may demonstrate caring practices, address diversity needs, and be used for patient/family teaching; however, the main outcome of effective communication is patient safety.

18. The spouse of a patient who is hospitalized in the critical care unit following resuscitation for a sudden cardiac arrest at work demands to meet with the nursing manager. The spouse demands, "I want you to reassign us to another nurse. His current nurse is not in the room enough to make sure everything is okay." The nurse recognizes that this response most likely is due to the spouse's a. desire to pursue a lawsuit if the assignment is not changed. b. inability to participate in the husband's care. c. lack of prior experience in a critical care setting. d. sense of loss of control of the situation.

d. sense of loss of control of the situation. ANS: D Demanding behaviors often occur when the family member has a sense of loss of control or has had adverse outcomes in a previous hospitalization. Prevention of a lawsuit is not relevant to this scenario. No information is provided regarding whether the family member is participating in care or not. It is unknown whether the spouse had a prior negative experience.

9. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to: a. anxiety. b. pain. c. powerlessness. d. sensory overload.

d. sensory overload. ANS: D Constant noise is a source of sensory overload. Pain and lack of information contribute to anxiety. Noise does not cause physical pain. Lack of involvement in care causes powerlessness.

7. The charge nurse is responsible for making the patient assignments on the critical care unit. An experienced, certified nurse is assigned to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. The nurse with less than 1 year of experience is assigned to two patients who are more stable. This assignment reflects implementation of the a. crew resource management model. b. National Patient Safety Goals. c. Quality and Safety Education for Nurses (QSEN) model. d. synergy model of practice.

d. synergy model of practice. ANS: D This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the nurse competencies are matched to the patient characteristics. Crew resource management concepts are related to team training; National Patient Safety Goals are specified by The Joint Commission to promote safe care but do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted education of undergraduate and graduate nursing students on quality and safety concepts.

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

d. teach the family that emotional outbursts are common after strokes. Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control, and asking the patient to stop will lead to embarrassment.

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

d. tissue plasminogen activator (tPA) infusion. The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry.

d. to call the health care provider if stools are bloody or tarry. Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

3. The main purpose of certification is to a. assure the consumer that you will not make a mistake. b. prepare for graduate school. c. promote magnet status for your facility. d. validate knowledge of critical care nursing.

d. validate knowledge of critical care nursing. ANS: D Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free. Certification does not prepare one for graduate school; however, achieving certification demonstrates motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses; however, that is not the purpose of certification.