Med Surg Exam 5 Redo

A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood-tinged and asked what that meant. The correct reply is?

. Pink or bloody CSF may indicate a subarachnoid bleed or local trauma from the puncture.

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

A client who has undergone a lumbar puncture should be positioned flat and given hydrating fluids. These measures help restore the cerebrospinal fluid volume extracted from the client. The nurse should also assess the L O C or the pupil response of the client after a lumbar puncture.

Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin "slice" of a muscular body area?

A computer tomography CT scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or "slices," of the body.

A client presents to the emergency department status post-seizure. The healthcare provider wants to measure CSF pressure. What test might be ordered on this client?

A lumbar puncture or spinal tap is performed to obtain samples of C S F from the subarachnoid space for laboratory examination and to measure CSF pressure.

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?

A pustule has an elevated, raised border, filled with pus

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate that the client is in comatose state?

A score of 7 or less is considered a coma.

A client was burned in a home accident. The ED physician indicated the client's wound, with proper care, should heal within 2 weeks. How was this client's wound classified?

A second-degree partial-thickness

A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications. Select all that apply.

A severe headache, weakness of one side of the body, slurred speech, and difficulty waking the client should be reported or treated immediately.

In an industrial accident, a 155 lb patient sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

A urine output consistently above 40 ml/hour

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test?

Biopsies

An ED nurse has administered an ordered bolus of tissue plasminogen activator t P A to a male patient who was diagnosed with stroke. During the administration of t P A, the nurse should prioritize assessments related to what problem?

Bleeding or Hemorrhage is the most common side effect of tPA.

On a Glasgow Coma scale, what is a score of 7 and below considered?

Comatose.

An older client reports a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect?

Headache and papilledema are symptoms of a brain tumor

A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington's disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington's disease.

Huntington's disease causes profound changes in personality and behavior.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident C V A should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Impaired Swallowing was evident on the video fluoroscopy.

A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?

In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test.

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristics associated with the postictal state?

In the postictal state or after the seizure, the patient is often confused, hard to arouse, and may sleep for hours.

The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?

Keloid is hypertrophied scar tissue secondary to excessive collagen formation during healing. It has an elevated, irregular, red appearance and occurs more often in African Americans.

An older adult has encouraged the spouse's husband to visit their primary provider, stating concern that the spouse may have Parkinson's disease. Which description of the spouse's health and function is most suggestive of Parkinson's disease?

Lately, he seems to move far more slowly than he ever has in the past.

The most accurate method of assessing the total body surface area is through the use of which assessment tool?

Lund and Browder method. The Lund and Browder method divides the body into smaller segments.

Which neurons transmit impulses from the CNS?

Motor neurons transmit impulses from the CNS. Sensory neurons transmit impulses to the CNS.

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. How is this done to assess for neck rigidity?

Moving the head and chin toward the chest

A client who has sustained a non-depressed skull fracture is admitted to the acute medical unit. Nursing care should include?

Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the client is essential.

The nurse is caring for a client with herpes zoster. What symptom(s) can the nurse anticipate?

Pain and itchiness. Rash appear first as vesicles and then rupture into crusts. A secondary skin infection can begin.

What is a patch test used for?

Patch tests may be used to determine allergies.

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, what should the nurse access?

Post-recovery from burns can be psychologically challenging; the nurse's assessments must address the patient's psychosocial state

When admitting a client to the hospital, what should the nurse do initially to prevent pressure injuries?

Prevention of pressure injuries first involves identifying persons who are at greatest risk.

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern?

Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.

A nursing student is caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician orders an epidural blood patch test. The student asks how this will help the headache. The correct reply is?

The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid.

What is the outermost layer of the protective covering of the brain and spinal cord?

The dura mater

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid C S F.

An ED nurse is admitting a client brought in by the paramedics after falling from a tree. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client?

The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage.

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event?

The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces.

An 80-year-old client is brought to the clinic by one of the client's children. The client asks the nurse why the client has gotten so many "spots" on the skin. What would be an appropriate response by the nurse?

The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions.

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

The meninges have three layers: the dura mater, arachnoid mater, and pia mater.

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?

The most prominent clinical features of the disease are chorea which are rapid, jerky, involuntary, purposeless movements, impaired voluntary movement, intellectual decline, and often personality changes.

A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?

The nurse is most concerned that the client is prescribed warfarin because this is a blood thinner. Due to the action of the medication, the client is at a high risk for intracranial bleeding.

Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question?

The oculomotor 3, abducens 6 and trochlear 4 nerves all work within the functional realm of the eyes. Don't forget the optic 2 nerve!

Which cranial nerve is responsible for muscles that move the eye and lids?

The oculomotor 3rd cranial nerve is responsible for pupillary constriction and lens accommodation.

What is the innermost membrane of this protective covering?

The pia mater

A client with a burn injury is in acute stress. What complications are they more prone to develop?

The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to developing gastric Curling's ulcer.

A client has been diagnosed with melanoma. What treatment option can the nurse expect will be used?

The treatment of a melanoma involves radical excision of the tumor and adjacent tissues, followed by chemotherapy.

What is the purpose of a Biopsy?

They are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis.

A burn involving a total destruction of the epidermis, dermis, and subcutaneous tissue is to what degree?

Third-degree full-thickness Wound characteristics include red, white, tan, brown, or black; leathery covering, eschar; painless

A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response?

Through the application of extreme cold, the tissue is destroyed.

When being discharged from the burn unit after having skin grafting done, what instructions should the client receive about the use of a pressure garment?

Wear the pressure garment at least 23 hours a day. Follow the manufacturer's instructions for donning and removing the pressure garment. Contact the physician if the garment causes discomfort or does not seem to fit properly.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

A burn involving all layers of the skin and into the muscle and bone is to what degree?

fourth-degree full thickness. Wound characteristics include black, depressed, painless, and scarring.

Which cerebral lobes is the largest and controls abstract thought?

frontal lobe

Which lobe contains the written and motor speech areas?

frontal lobe

The nurse is caring for a client who is scheduled for a cervical discectomy the following day. During health education, the client should be made aware of what potential complications.

hematoma at the surgical site, resulting in cord compression, neurologic deficit, and recurrent or persistent pain after surgery

A flat, round, colored lesion such as a freckle or rash is called?

macule

The nurse collects neurologic data and determines that the client has significant visual deficits. A brain tumor is considered. Which area of the brain does the nurse consider to be most likely to contain the neurologic deficit?

occipital lobe

Which lobe is the primary sensory area of the brain?

parietal lobe

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

patient is Lethargy A decreasing level of consciousness is one of the earliest signs of increased intracranial pressure I C P.

A bedridden patient is admitted to the unit because of a pressure injury. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury?

stage 4 because of the exposed muscle and bone

What level of consciousness is the patient in when the patient is aroused only with vigorous and repeated stimulation?

stupor

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the:

sympathetic nervous system.

Which lobe is the auditory receiving and association area of the brain, and is responsible for speech comprehension?

temporal lobe

What is the goal of fluid resuscitation in a patient with burns?

to maintain arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour.

cryosurgery

use of cold temperatures to destroy tissue. often by using liquid nitrogen.

A lesion that is elevated, round, and filled with serum such as a blister is called?

vesicle

Which zones of burn is at the center of the injury and is the area of injury that is most severe and the deepest?

zone of coagulation

Which zones of burn is the area of least injury, where the epidermis and dermis are only minimally damaged.?

zone of hyperemia

Which zones of burn is where blood vessels are damaged, but the tissue has potential to survive?

zone of stasis

What is the responsibility of cranial nerve 5th?

The Trigeminal nerve is responsible for sensation to the face and chewing.

What is the responsibility of cranial nerve 4th?

The Trochlear nerve is responsible for extraocular movement.

What is the responsibility of cranial nerve 8th?

The Vestibulocochlear nerve is responsible for hearing and balance.

What is the middle membrane of the brain?

The arachnoid mater

What imaging procedure is using ultrasound, to detect the structures of the brain?

A Echoencephalography

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Administer acetaminophen to try to manage the client's pain without causing sedation. Then reassess the client in 30 minutes to note the effectiveness of the pain medication.

The nurse is caring for a client who is undergoing single-photon emission computed tomography SPECT. What is a potential side effect that this client may suffer?

Allergic reaction to the imaging material

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?

An electromyogram is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles.

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?

An escharotomy is an incision into the eschar to relieve pressure on the affected area.

Which medication classification is prescribed when allergy is a factor causing the skin disorder?

Antihistamines are frequently prescribed when an allergy is a factor in causing the skin disorder. They relieve itching and shorten the duration of allergic reaction.

A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication?

As edema increases, pressure on small blood vessels and nerves in the distal extremities obstructs blood flow and consequent ischemia. This complication is similar to compartment syndrome.

A client with a T4 level spinal cord injury is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency.

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?

cranial nerve 12, the hypoglossal nerve

An encapsulated, round, fluid-filled, or solid mass beneath the skin is called?

cyst

What is the responsibility of cranial nerve 11th?

The Accessory nerve is involved with head and shoulder movement.

What is the responsibility of cranial nerve 7th?

The Facial nerve is responsible for salivation, tearing, taste, and sensation in the ear.

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

Cerebral angiography

What imaging procedure is used to detect distortion of the cerebral arteries and veins such as an aneurysm?

Cerebral angiography

The nurse recognizes that causes of acquired seizures include what?

Cerebrovascular disease. Metabolic and toxic conditions. Hyponatremia. Brain tumor. Drug and alcohol withdrawal.

What is the purpose of a chemical face peel?

Chemical face peeling is especially useful for wrinkles at the upper and lower lip, forehead, and periorbital areas.

What is the responsibility of cranial nerve 9th?

The Glossopharyngeal nerve is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

Cranial nerve 12, the hypoglossal nerve, controls tongue movements involved in swallowing and speech.

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?

Cranial nerve 8 is the vestibulocochlear nerve

What is the responsibility of cranial nerve 12th?

The Hypoglossal nerve is involved in the movement of the tongue.

The nurse is preparing a client for a neurological examination and explains the tests the physician will be doing, including the Romberg test. The client asks what is the purpose of this particular test. The correct reply by the nurse is?

The Romberg test screens for balance.

The nurse is caring for a client with head trauma. Which assessment finding would indicate an increasing intracranial pressure I C P in this client?

Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing I C P. Other signs of Cushing's triad include bradycardia and irregular breathing.

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?

Emotional problems associated with stroke are often related to the new challenges around ADLs and communication.

Which posture is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

A nurse is performing a skin assessment on a client with diabetes and notes furuncles and carbuncles to both lower legs. The client states their skin typically has "issues" but eventually heals if left alone. What targeted teaching topics would most benefit this client?

Discuss treatment concerning bacterial infections, blood glucose levels, and basic skin maintenance techniques.

A client has extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?

During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin.

The spouse of a client who was struck by lightning asks the nurse why the areas involved seem so small but the damage is extensive. Which is the best explanation from the nurse?

Electrical burns usually follow an internal path. The skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way.

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in determining brain death?

Electroencephalography E E G

Which of the following are the immediate complications of spinal cord injury?

Respiratory arrest and spinal shock are the immediate complications of spinal cord injury.

. A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis A L S. The nurse should prioritize assessments related to which of the following?

Respiratory function is profoundly affected by A L S

What does a Single-photon emission computed tomography SPECT imaging test detect?

SPECT is an imaging tool that examines cerebral blood flow.

A burn involving deep layers of the dermis with damage to the sweat and sebaceous glands is to what degree?

Second-degree deep partial thickness. Wound does not blanch with pressure, sensitive to pressure only

A burn associated with blister formation is to what degree?

Second-degree superficial partial thickness. Damage to the epidermis, dermis, but hair follicles intact. Looks mottled pink to red, painful, blistered or exuding fluid, n blanches with pressure. Heals within 14 days, with some pigmentary changes but no scar. No surgical intervention require.

The nurse is assessing a client's level of consciousness. She speaks the client's name, strokes the client's hand, n moves the client's shoulder. There is a delay, before client states, "What do you want?" n falling asleep again. Which level of consciousness should the nurse document?

Somnolent or lethargy

What level of consciousness is the patient in when they are drowsy or sleepy at inappropriate times and can be aroused only to fall back asleep?

Somnolent or lethargy

An area of erythema that does not blanch with pressure is considered at what stage of an ulcer?

Stage 1 pressure sores are characterized by redness of intact skin.

A break in the skin that may drain is considered at what stage of an ulcer?

Stage 2 is the same as stage 1 but has a blister or shallow break in the skin.

The nurse is caring for a client in the long-term care facility who has developed a "bed sore." The nurse observes a serous drainage covering the dressing and a 2 x 2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure injury as?

Stage 3 has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue.

An ulcer that extends into the subcutaneous tissue is considered at what stage?

Stage 3 is characterized by superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue.

The nurse is going to visit a client with a pressure ulcer who is being cared for by family members in the home. The nurse changed the dressing and observed the healing status. The wound is 6 × 7 cm and 2 cm deep and exposes muscle. What does the nurse document this wound as?

Stage 4 has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.

An ulcer that extends to underlying muscle and bone is considered at what stage?

Stage 4 is characterized by extensive tissue damage that is deeply ulcerated, exposing muscle and sometimes bone. Necrosis of tissue and infection may develop.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

The 3 most common GI alterations in burn-injured patients are 1. paralytic ileus is the absence of intestinal peristalsis. 2. Curling's ulcer 3. Translocation of bacteria. 4. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

What is the responsibility of cranial nerve 6th?

The Abducens nerve is responsible for lateral eye movement.

What imaging procedure is used to record electrical impulses generated by the brain such as when a patient is brain dead?

a Electroencephalogram EEG detect

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established. Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care.

The nurse teaches the client who demonstrates herpes zoster or shingles that

a person who has had chickenpox can contract it again upon exposure to a person with shingles.

What level of consciousness is the patient in when the patient only responds to superficial, relatively mild painful stimuli?

as semi-comatose

What level of consciousness is the patient in when the patient only responds to very painful stimuli by fragmentary, delayed reflex withdrawal or loses all responsiveness?

comatose