MEDSURG II FINAL
Patient teaching for crutches
-Support your weight with your arms and hands, NOT your armpits (could hurt nerves) -Keep elbow bent -Walk slowly
How do you go up the stairs with crutches?
1. Put crutches close to the first step 2. Put uninjured leg on first step 3. Put weight on uninjured leg and bring both crutches and injured leg onto the step at the same time
The nurse assesses vital signs, skin color, and LOC in a patient with a suspected pelvic fracture to indicate what? A. Hypovolemic shock B. Compartment syndrome C. Fat embolism syndrome D. Infection
Answer : A
What drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? A. Nicotinic acid B. Diuretics C. Antihistamines D. Antipyretics
Answer: B Mild diuretics are prescribed to decrease endolymph volume. Ménière's disease causes an excess of endolymphatic fluid that distorts the entire inner-canal system.. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus. Antihistamines and antipyretics do not decrease endolymph volume. Nictonic acid has been found to be useful because of its vasodilatory effect, but it does not decrease endolymph volume.
The nurse recognizes that the most common type of stroke is related to which of the following? A. Ischemia B. Hemorrhage C. Headache D. Vomiting
Answer: A 80% of all strokes are caused by ischemia. Hemorrhagic strokes are less common than ischemic strokes. Headache and vomiting may be symptoms associated with CVA, but not causes.
A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat emboli? A. Altered mental status B. Reduced bowel sounds C. Swelling of the toes distal to the injury D. Pain with passive movement of the foot distal to the injury
Answer: A Altered mental status is an early manifestation of fat emboli. Other manifestations include dyspnea, chest pain, and hypoxemia. Reduced bowel movements is an adverse effect of opioid narcotics. Swelling of the toes distal to the injury is a manifestation of reduced circulation due to a tight cast. Pain with passive movement of the foot distal to the injury is expected. Severe pain or pain unrelieved by narcotics is symptomatic of compartment syndrome.
The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? A. "I should spend all my time with my husband in case I'm needed" B. "My husband must take his medicine every day to prevent another stroke" C. "My husband may get depressed" D. " The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed"
Answer: A Although well intentioned, family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured day-care respite program or through relief provided by a friend or neighbor.
The nurse is assessing a client with a TBI after a skateboarding accident. Which sign/symptom is the nurse most concerned about? A. Asymmetric pupils B. Head laceration C. Headache D. Amnesia
Answer: A Asymmetric pupils are treated as herniation of the brain from increased intracranial pressure (IICP) until proven otherwise. Amnesia, headache, and a head laceration can be signs of a mild TBI and need to be investigated more thoroughly.
A client with a TBI from a MVA is monitored for signs/symptoms of IICP. Which signs/symptoms does the nurse monitor for? A. Changes in breathing pattern B. Dizziness C. Reactive pupils D. Increased LOC
Answer: A Changes in breathing pattern may be indicative of IICP secondary to compression of areas of the brain responsible for respiratory control. Dizziness is a symptom of brain injury, not IICP. Increasing LOC and reactive pupils are desired for this client.
A client is taking long-term corticosteroids for Myasthenia Gravis. What teaching point is most important? A. Avoid large crowds and people who are ill B. Check blood sugar 4 times a day C. Use 2 forms of contraception D. Wear properly fitting socks and shoes
Answer: A Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead so secondary diabetes, but the client would not need to start checking blood sugar unless diabetes is detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.
A patient with a SCI is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? A. Autonomic dysreflexia B. Autonomic crisis C. Autonomic shutdown D. Autonomic failure
Answer: A Distended bladder must be prevented when caring for SCI so that it doesn't lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder screening can help prevent it.
A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A. F-A-S-T B. A-V-P-U C. K-I-N-D D. O-P-Q-R-S-T
Answer: A Face, Arms, Speech, Time teaches the family and patient how to recognize and respond to a stroke. AVPU (alert, verbal, painful, unresponsive) is for the level of awareness. KIND (kayexalate, insulin, NaHCO3, diuretics) is for the treatment of hyperkalemia. OPQRST (onset, provokes, quality, radiates, severity, time) is for assessing pain.
A client has been admitted with a Dx of a stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits what symptoms? A. Impulsiveness and smiling B. Aphasia and cautiousness C. Quick to anger and frustration D. Inability to discriminate words
Answer: A Impulsiveness and smiling indicate a right hemisphere stroke. Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration indicate a left hemisphere stroke.
An older client is hospitalized with GBA. A family member tells the nurse the client is restless and seems confused. What action by the nurse is the best? A. Assess the client's oxygen saturation B. Check the medication list for interactions C. Place the client on a bed alarm D. Put the client on safety precautions
Answer: A In the older adult, an early signs of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation.
A client with MG asks the nurse to explain the disease. What response by the nurse is the best? A. "MG is an autoimmune problem in which nerves do not cause muscles to contract" B. "MG is an inherited destruction of peripheral nerve endings and junctions" C. "MG consists of trauma-induced paralysis of specific cranial nerves" D. "MG is a viral infection of the dorsal root of sensory nerve fibers"
Answer: A MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not inherited, is not viral, and does not paralyze specific cranial nerves.
A client has a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in the client's teaching plan? A. "Use pain medication as prescribed to control pain" B. "Apply Neosporin if signs or symptoms of infection develop around the pin sites" C. "Wear the same clothing that you normally wear" D. "Clean the pin site when any drainage is noticed"
Answer: A Teaching the correct use of prescribed pain medication should be included in the client's teaching plan. Pin sites must be cleaned every 8 hours and as needed, not when any drainage is noticed. The client will have to adjust their clothing while the fixation device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify their doctor immediately. Infection of the pin sites can cause osteomyelitis.
Which patient is at highest risk for a SCI? A. 18 y.o. M with a prior arrest for a DUI B. 20 y.o. F with a history of substance abuse C. 50 y.o. F with osteoporosis D. 25 y.o. M who coaches a soccer team
Answer: A The 3 major risk factors for SCIs are age (young adults), gender (higher in males), and alcohol or drug abuse. Since this patient is both younger and a male, he is at the highest risk.
When caring for a patient who is post-CVA who has altered consciousness, the nurse should place the patient in which position? A. Side-lying B. Supine C. Prone D. Semi-fowler's
Answer: A The side-lying position is the safest position to allow adequate drainage of fluids without aspiration.
A dying patient's family is heard telling them to "calm down", and the nurse observes the client being agitated and making repetitive motions. What does the nurse do? A. Suggests the family tell the client that everything is "all right" B. Asks the family to speak in low tones or whispers to avoid disturbing the client C. Recommends giving the client antianxiety medications to reduce distress D. Offers to call and have the hospital chaplain come to help the client calm down
Answer: A When dying clients are agitated or performing repetitive tasks, it is often a sign that they have unfinished or unresolved issues that prevent letting go. Suggesting that the family members tell the patient that it will be all right and that it is ok to go can help the client relax and let go. The client needs to know that their family is present and concerned. Having a chaplain calm them down or giving them antianxiety medications will not resolve the underlying issue.
A client with MG is prescribed Mestinon. What teaching should the nurse plan regarding this medication? Select all that apply. A. "Do not eat a full meal for 45 minutes after taking" B. "Seek immediate care if you develop difficulty swallowing" C. "Take this drug on an empty stomach for best absorption" D. "The dose may change frequently depending on symptoms" E. "Your urine may turn a reddish-orange color while taking this drug"
Answer: A, B, D Mestinon should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If dysphagia occurs, the patient should seek immediate medical attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client's urine output will not turn reddish-orange while on this drug.
Prodromal manifestations prior to an intracranial aneurysm rupture could be recognized by the nurse as which of the following? Select all that apply. A. Visual deficits B. Headache C. Mild nausea D. Dilated pupil E. Stiff neck
Answer: A, B, D Often intracranial aneurysms are asymptomatic until rupture, but patients can complain of headache and eye problems including visual deficits and dilated pupils. Nausea and vomiting and stiff neck are not usually associated with the prodromal manifestations of aneurysm, but may occur with leaking and rupture.
What are the risk factors for stroke? Select all that apply. A. High blood pressure B. Female gender C. Smoking D. Use of oral contraceptives E. Previous stroke or transient ischemic attack (TIA)
Answer: A, C, D, E
A patient with an SCI was given IV Decadron (dexamethasone) after arriving in the E.R. The patient also has history of hypoglycemia. During the hospital stay, the nurse would expect to see which of the following? A. Increased episodes of hypoglycemia B. Possible episodes of hyperglycemia C. No change in the patient's glycemic parameters D. Both hyper- and hypoglycemic episodes
Answer: B A common side effect of corticosteroids is hyperglycemia
The nurse is education a patient and family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-wells tongs? A. "I will have less pain if I use the halo device" B. "The halo device will allow me to get out of bed" C. "I am less likely to get an infection with the halo device" D. "the halo device does not have to stay in place as long"
Answer: B A halo device will allow patients to get out of bed since it does not require weights like the Gardner-Wells tongs. The patient's pain level is not dependent on the type of stabilization device used. The patient does not have a great risk of infection with the Gardner-Wells tongs; both devices require pins to be inserted into the skull. The time required for stabilization is not dependent on the type of stabilization device used.
A patient with a SCI at the T1 level complains of a severe headache and an "anxious" feeling. Which is the most appropriate initial reaction by the nurse? A. Try to calm the patient and make the environment soothing B. Assess for a full bladder C. Notify the healthcare provider D. Prepare the patient for diagnostic radiography
Answer: B Autonomic dysreflexia occurs in patient with injury at the T6 level or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, anxiety, bradycardia, visual changes, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.
The nurse understands that with a SCI, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extend of the injury cannot be determined for several days to a week? A. "Tissue repair does not begin for 72 hours" B. "The edema extends the level of the injury for 2 cord segments above and below the affected level" C. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses" D. "Necrosis of gray and white matter does not occur until days after the injury"
Answer: B Because the edema extends above and below the affected area, the extend of the injury cannot be determined until after the edema is controlled. Within 24 hours of necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extend of the injury.
A nurse in the emergency department is planning care for a client with a right hip fracture. Which immobilization device should the nurse include in the plan of care? A. Skeletal traction B. Buck's traction D. Halo traction E. Bryant's traction
Answer: B Buck's traction is applied to client's with femur or hip fractures to diminish muscle spasm immobilize the area until surgery. Skeletal traction is applied to long bone and cervical spine fractures. Halo traction immobilizes the cervical spine in cervical fractures. Bryant's traction is used for congenital hip dislocation in children.
A client recovering from a stroke reports double vision that is preventing them from effectively completing ADLs. How does the nurse help the client compensate? A. Approaches the client on the affected side B. Covers the affected eye C. Encourages turning the head from side to side D. Places objects in the client's field of vision
Answer: B Covering the client's affected eye with a patch will prevent diplopia. The client recovering from a stroke will always be approached on the unaffected side. The nurse may encourage side to side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? A. Atenolol (Tenormin) B. Lorazepam (Ativan) C. Phenytoin (Dilantin) D. Lisinopril (Prinivil)
Answer: B IV Lorazepam is administered to stop motor movements. This is then followed by the administration of Phenytoin. Atenolol, a beta-blocker, and Lisinopril, an ACE inhibitor, are not administered for seizure activity. These are typically administered for hypertension and heart failure.
What condition in a dying client requires that a nurse take action? A. Cool extremities B. Moaning C. Anorexia D. Alternating apnea and rapid breathing
Answer: B Moaning indicates pain which requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal findings in a dying client.
An older adult client has multiple tibia and fibula fractures of the left extremity after a MVA. Which pain medication does the nurse anticipate will be requested for this client? A. Cyclobenzaprine (Flexeril) B. PCA with morphine C. Ibuprofen (Advil) D. Meperidine (Demerol)
Answer: B Morphine is an opioid narcotic analgesic and is given through PCA. It is the most appropriate mode of pain management for multiple injuries. Cyclobenzapine is a muscle relaxant effective in treating muscle spasms, not acute pain. Ibuprofen is an NSAID that is used to treat mild to moderate pain, not severe pain like this patient is having. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.
A client's family wants to remove the client's ventilator and stop treatment. What does the nurse do? A. Removes the interventions, per the family's wishes B. Facilitates a meeting between the family and the health care team C. Tells the family that removing the interventions is illegal D. Waits to obtain information on the client's wishes
Answer: B Removing or pausing life-sustaining therapy can result in the end of the patient's life. To do this, a meeting is required. Withdrawing life support requires more than just the family's wishes. Removal of the therapy is not illegal except in cases of euthanasia or physician-assisted euthanasia. The client most likely will not regain consciousness. The client's wishes should have been determined and documented earlier via an A.D. or will.
A patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment, the findings are: BP 90/60 (lowered from 136/66 in the ER), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? A. Paralysis B. Spinal shock C. High cervical injury D. Temporary hypovolemia
Answer: B Spinal shock is common in acute spinal cord injuries. Lack of respiratory effort is associated with high cervical injury.
A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? A. Suggest temporary removal of the hearing aid B. Refer the client to the American Tinnitus Association C. Provide further assessment D. Suggest a quiet environment
Answer: B The ATA assists clients in coping with tinnitus when other therapy is not successful. Reassessment of the client's diagnosis is not needed; this will only waste the client's and the nurse's time. A quiet environment and removal of hearing aid will not be helpful. Background noise masks the tinnitus while quiet conditions exacerbate it. Ear-mold hearing aids can amplify sounds to drown out tinnitus during the day.
A client is admitted with a stroke. Which tool does the nurse use to facilitate a focused neurologic assessment of the client? A. Mini-Mental State Examination (MMSE) B. National Institutes of Health Stroke Scale (NIHSS) C. Intracranial pressure monitor D. Glasgow Coma Score (GCS)
Answer: B The nurse uses the NIHSS tool because it is a designated stroke center. GCS provides a non-specific indication of LOC. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.
Which of the following is the priority NDx for the patient who has undergone spinal fusion surgery? A. Acute pain B. Impaired mobility C. Risk for infection D. Risk for injury
Answer: B The priority NDx after a spinal fusion surgery is impaired mobility due to the assessment of ABCs. Impaired mobility can affect circulation, therefore affecting tissue perfusion and causing a risk for skin breakdown.
The family of a patient who has had a CVA asks if the patient will ever talk again. The nurse should do which of the following? A. Explain that the patient's speech will return to normal with time B. Explain that it is difficult to know how far the patient will progress C. Tell the family that nurses cannot discuss such issues and that they should ask the physician D. Tell the family what they see today is what they can expect.
Answer: B Therapeutic communication is needed. It is important to allow hope but be honest by not promising progress, since no one knows how the patient will improve. The nurse does not know that speech will return in time. It is not therapeutic to tell the family to ask the physician, and it does not display a professional, caring attitude.
A nurse assesses a client with a PMH of epilepsy who experiences stiffening of the muscles in the arms and legs, followed by an immediate LOC and jerking of all extremities. How should the nurse document this activity? A. Atonic seizure B. Tonic-clonic seizure C. Myoclonic seizure D. Absence seizure
Answer: B This is characteristic of a tonic-clonic seizure. An atonic seizure presents as sudden loss of muscle tone followed by confusion. A myoclonic seizure presents with brief jerking or stiffening of arms and legs. Absence seizures present with automatism's (involuntary actions), and the client is unaware of their environment
A client has an open fracture of the right tibia. To prevent infection, which intervention does the nurse implement? A. Leave the site open to the air to keep it dry B. Use strict aseptic techniques when cleaning the site C. Assist the client to shower daily and pat the wound site dry D. Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab
Answer: B Using aseptic technique is the best way to prevent infection. Chlorhexidine (Hibiclens) is better for cleaning the site, not Neosporin. This wound should be covered, not left open. The wound site of an open fracture must not be exposed to a shower because it is not aseptic.
A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? A. "I will stop taking this medicine if I notice any bruising" B. "I will not eat spinach while I'm taking this medicine" C. "It will be OK for me to eat anything, as long as it is low-fat" D. "I'll check my BP frequently while taking this medication"
Answer: B Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of this drug. Bruising is a common side effect, and the drug should not be stopped unless ordered by the doctor. Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.
The nurse must be alert to complications in the patient who has suffered a ruptured intracranial aneurysm. The nurse should assess the patient for signs of which of the following? Select all that apply. A. Headache B. Hydrocephalus C. Rebleeding D. Vasospasm E. Stiff neck
Answer: B, C, D Headache is a sign of possible re-bleed. Hydrocephalus, re-bleeding, and vasospasm are the 3 major complications that a nurse MUST anticipate following a ruptured intracranial aneurysm. Stiff neck is a manifestation of aneurysm, not a complication.
A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. A. Continuous sedation B. Siderails raised C. Suction equipment at the bedside D. IV E. Bite block at the bedside
Answer: B, C, D IV access is needed for medication administration. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure. Bite blocks or padded tongue blades could cause the patient to break them with their jaws and obstruct the airway. Continuous sedation is a medical intervention and not a seizure precaution.
An older client is hospitalized with GBS. The client is given Amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are the most important? Select all that apply. A. Administering the medication as ordered B. Advising the client to have help getting up C. Consulting the provider about the drug D. Cutting the dose of the drug in half E. Placing the client on safety precautions
Answer: B, C, E Amitryptyline is a TCA and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.
A client with Myasthenia Gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A. Assessing the client's gag reflex B. Cutting foods up into small bites C. Monitoring prealbumin levels D. Thickening liquids prior to drinking E. Weighing the client daily
Answer: B, D
The nurse is providing medication instructions for a client prescribed phenytoin (dilantin) for the treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Apple juice B. Prune juice C. Grape juice D. Grapefruit juice
Answer: D Grapefruit juice can interfere with the metabolism of phenytoin, which can lead to an increased blood level and toxicity.
What is a complication of musculoskeletal trauma? A. Nerve loss B. Fractures C. Avascular necrosis D. Dyspnea
Answer: C
A client with a fracture asks the nurse about the difference between an open fracture and a simple fracture. Which statement by the nurse is correct? A. "Simple fracture involves a break in the bone with skin contusions" B. "Simple fracture has an increased risk for infection and emboli" C. "An open fracture involves a break in the bone, with damage to the skin" D. "An open fracture does not extend through the skin"
Answer: C A simple fracture does not extend through the skin, and an open fracture has an increased risk for infection, not a simple fracture.
A client with GBS is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? A. Anxiety B. Low fluid volume C. Inadequate airway D. Potential for skin breakdown
Answer: C Airway always takes priority. Anxiety is probably present, but a physical diagnosis takes priority of a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink. If present, airway problems take priority over a circulation problem.
The nurse is preparing a client for a Tensilon (endrophonium chloride) test. What action by the nurse is most important? A. Administering anxiolytics B. Having a ventilator nearby C. Obtaining atropine sulfate D. Sedating the client
Answer: C Atropine is the antidote to endrophonium chloride and should be readily available during a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.
While caring for a patient with SCI, the nurse elevates the HOB, removes compression stockings, and continues to assess vitals every 2 to 3 minutes while searching for a cause in order to prevent LOC or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is what? A. Hypoxia B. Bradycardia C. Elevated BP D. Tachycardia
Answer: C Autonomic dysreflexia is an an emergency that requires immediate assessment and intervention to prevent complication of extreme hypertension.
A client is admitted with Guillain-Barre syndrome (GBS). What assessment takes priority? A. Bladder control B. Cognitive perception C. Respiratory system D. Sensory functions
Answer: C Clients with GBS have muscle weakness, possibly to the point of paralysis.. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is priority.
A client in the ER has slurred speech, confusion, and visual problems with worsening symptoms. The symptoms have a gradual onset, and the client also has a PMH of hypertension and atherosclerosis. What does the nurse suspect that the client is experiencing? A. Transient ischemic attack B. Embolic stroke C. Thrombotic stroke D. Hemorrhagic stroke
Answer: C Due to its gradual onset, the client's signs and symptoms indicate a thrombotic stroke. S&S of embolic stroke have a sudden onset. S&S of hemorrhagic stroke are sudden and severe headaches. S&S of transient ischemic attacks are slurred speech, confusion, and visual problems and are "warning signs" of an ischemic stroke (thrombotic strokes are a category of ischemic strokes).
A school nurse is called after a student falls down the stairs. The student is breathing, but unconscious. After calling the ambulance, which is the most appropriate action by the nurse? A. Protect the patient's neck and head from any movement B. Place the patient on his side to prevent aspiration C. Immobilize the neck, securing the head D. Try to rouse the patient by gently shaking his shoulders.
Answer: C Guidelines for emergency care are avoiding flexing, extending, or rotating the neck, immobilizing the neck, securing the head, maintaining the patient in the supine position, and transferring from the stretcher with backboard in place to the hospital bed.
A hospitalized patient becomes unresponsive. The left side of the body is flaccid. The attending physician believes that the patient may have had a stroke (CVA). What is the nurse's priority intervention? A. Move the patient to the critical care unit B. Assess blood pressure C. Assess the airway and breathing D. Observe urinary output
Answer: C In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of the highest priority and will continue to be. Blood pressure and output monitoring as well as ensuring appropriate level of care are important interventions, but assessment of the patient's ability to maintain an airway is the most vital.
Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? A. Fluid volume deficit B. Impaired physical mobility C. Ineffective airway clearance D. Altered tissue perfusion
Answer: C Ineffective airway clearance is the priority nursing diagnosis for this patient. The nurse utilizes the ABCs to determine priority. Fluid volume deficit is the nurse's second priority (circulation), and then altered tissue perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is impaired physical mobility.
A client has a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent IICP? A. Assessing for Grey Turner's sign B. Placing the client in Trendelenburg position C. Maintaining neutral head position D. Suctioning the client frequently
Answer: C Maintaining the head in a neutral position prevents obstruction of blood flow and is an important component of ICP. Grey Turner's sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The HOB needs to be at 30 degrees; Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning should be avoided because it can cause IICP.
A patient is receiving plasmapheresis. What action by the nurse best prevents infection in this client? A. Giving antibiotics prior to treatments B. Monitoring the client's vital signs C. Performing appropriate hand hygiene D. Placing the client in protective isolation
Answer: C Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.
A hospice patient has died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? A. Notify the spouse and other family members B. Assess the client for cessation of respiratory effort and lack of pulse C. Remove IV lines or tubes according to hospice policy D. Document time of death and other data
Answer: C Removing IVs and tubes will prepare the body for viewing by the family or transfer to the morgue and is appropriate for a UAP.
The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following? A. Diabetes B. Heart disease C. Renal insuffciency D. Hypertension
Answer: D Hypertension is the greatest risk factor for CVA, and should be controlled. Diabetes, heart disease, and renal insufficiency can all lead to a stroke, however hypertension is the greatest risk.
The nurse is evaluating the collaborative care of a client with a TBI. What is the most important goal for this client? A. Preventing skin breakdown B. Achieving the highest level of functioning C. Preventing further injury D. Increasing cerebral perfusion
Answer: C The MOST important nurse's goal for a client with a TBI is to help him or her achieve the highest level of functioning. The nurse can assess cerebral perfusion, but cannot increase it. Prevention of injury is part of a larger goal for this client. Prevention of skin breakdown is a goal for the care of any client.
A dying client becomes withdrawn and reuses to eat and drink. What intervention does the nurse implement? A. Give IV hydration B. Brings in client's favorite food C. Offers ice chips D. Calls the family to come in
Answer: C The client's metabolic needs have decreased. They should not be forced to eat or drink, but offering ice chips is appropriate because this client is unable to swallow and it will help with dry mouth. IV won't be needed because the client is dying and the metabolic needs have decreased.
A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" What is in appropriate response by the nurse? A. "Know your family history" B. "Keep a list of your medications" C. "Be alert for sudden weakness or numbness" D. "Call 911 if you notice a gradual onset of paralysis or confusion"
Answer: C Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance. The key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of a stroke. Gradual onset of symptoms is not indicative of a stroke.
A client with hypertension presses the call light and reports "feeling funny". When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? A. Performs a neurologic check B. Assists the client to a sitting position C. Assesses ABCs D. Calls the provider
Answer: C When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must FIRST assess ABCs. Calling the Rapid Response Team, not the provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed but is not top priority. The client would be placed in bed so they are easily accessible for healthcare providers to assess and begin treatment, not sitting
Which groups are at the most risk for bacterial meningitis? Select all that apply. A. Older adults B. Pregnant women C. Military recruits D. College students E. Low-income people
Answer: C, D Military personnel living on a base and young adults living in close proximity are at a greater risk of contracting bacterial meningitis. The other populations are at a lower risk.
A dying client is agitated. Their foley catheter has drained 100 mL in 3 hours and they have not had a bowel movement since yesterday. What does the nurse do first? A. Assess the client for impaction B. Arrange for consultation with a bereavement counselor C. Change the foley to ensure adequate drainage D. Adminster an analgesic
Answer: D Agitation may be indicative of pain, which must first be addressed in a dying client. counselors, assessing for impaction are not priority since the client's metabolism has obviously slowed and they had a bowel movement the day before. The foley does not need to be changed; the tubing can be assessed to make sure there are no kinks.
The nurse learns that the pathyphysiology of GBS includes segmental demyelination. The nurse should understand that this causes what? A. Delayed afferent nerve impulses B. Paralysis of affected muscles C. Paresthesia in upper extremeties D. Slowed nerve impulse transmission
Answer: D Demyelination leadsd to slow nerve impulse transmission. The other options are not correct.
After teaching a client diagnosed with status epilepticus and prescribed phenytoin, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? A. "To prevent complications, I will drink at least 2 liters of water a day" B. "This medication will stop me from getting an aura before a seizure" C. "I will not drive a motor vehicle while taking this" D. "Even when my seizures stop, I will continue to take this medication"
Answer: D Discontinuing antiepileptic drugs can lead to recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while on this medication. The medication won't stop an aura before a seizure.
The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet? A. Meeting the client's needs B. Ensuring an expedited death C. Avoiding client distress D. Facilitating a peaceful death
Answer: D Facilitating a peaceful death is the goal for palliative care. Distress cannot be avoided but rather controlled. Expedited death is not a goal of palliative care. It is not possible to meat all of the client's needs.
A client with an open fracture of the left femur is admitted. Which action is most essential for the nurse to take first? A. Placing a dressing on the affected area B. Immobilize the left leg with a splint C. Administer the prescribed analgesic D. Check the dorsalis pedis pulses
Answer: D It is necessary to assess the circulatory status of the leg because this client is at risk for compartment syndrome which occurs between 6 to 8 hours after injury and can cause severe tissue damage due to decreased neurovascular status. Immobilization will be needed as well as analgesics and dressings, but the nurse must assess the client first.
A patient with a SCI has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? A. Hemiplegia B. Paresthesia C. Paraplegia D. Quadriplegia
Answer: D Quadriplegia: complete paralysis of upper and lower extremities Hemiplegia: paralysis on one side of the body Paresthesia: nothing to do with paralysis Paraplegia: Paralysis of the lower body
A patient is admitted with signs of a CVA. On admission, VS were BP 128/70, HR 68, RR 20. 2 hours later the patient is not awake, has a BP of 170/70, HR 52, and the left pupil is now slower than the right pupil in reaction to light. These followings suggest which of the following? A. Impending brain death B. Decreasing intracranial pressure C. Stabilization of the patient's condition D. Increased intracranial pressures
Answer: D Rising systolic BP, falling pulse, and a sluggish pupil suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician. The patient's condition is becoming unstable. Brain death is diagnosed by a lack of brain waves and inability to maintain vital function.
A patient with a C7 SCI begins to yell "I can't feel my legs anymore!". Which is the most appropriate action by the nurse? A. Remind the patient of her injury and try to comfort her B. Call the healthcare provider to get an order for radiology evaluation C. Prepare the patient for surgery, as her condition is worsening D. Explain to the patient that this could be a common, temporary problem
Answer: D Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury. The nurse explain what is happening to the patient.
A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? A. Start an IV B. Administer phenytoin (dilantin) C. Draw the client's blood D. Establish an airway
Answer: D The nurse must first establish an airway and then assess the client for the need of additional support during a seizure. Phenytoin is administered to prevent the recurrence of seizures, not to treat a current one. Drawing blood or starting an IV is not priority in this situation.
The nurse is administering the intake assessment for a newly admitted client with a PMH of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure B. Forces a tongue blade into the mouth C. Restrains the client D. Positions the client on their side
Answer: D Turning the client on their side during a seizure is indicated to maintain a patent airway should the Pt lose consciousness or begin to froth from the mouth. Documenting is important, but not a priority intervention. Tongue blades and restraining can cause injury.
A client with Myasthenia Gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client has been met? A. Ability to chew and swallow without aspiration B. Eating 75% of meals and between-meal snacks C. Intake greater than output 3 days in a row D. Weight gain of 3 pounds in 1 month
Answer: D Weight gain is the best indicator that the client is receiving enough nutrition Being able to chew and swallow is important for eating, but adequate can be accomplished through enteral means if needed. Swallowing w/o difficulty indicates an intact airway. Since the question does not indicate what the client's meals consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
A nurse assesses clients on a med-surg unit. Which clients should the nurse identify as at risk for secondary seizures? Select all that apply. A. 26 y.o. F with a left temporal brain tumor B. 38 y.o. M in an alcohol withdrawal program C. 42 y.o. M football player with a TBI D. 66 y.o. F with MS E. 72 y.o. M with COPD
Answers: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or TBI, and those who have a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a PMH of stroke, heart disease, and substance abuse are also at risk.
A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. A. "I will clean the pins twice a day" B. "I will use a separate cotton swab for each pin" C. "I will report loosening of the pins to my doctor" D. "I will move my leg by lifting the device in the middle" E. "I will report increased redness at the pin sites
Answers: A, B, C, E Cleaning the device pins one or two times each day will remove exudate that harbors bacteria. Separate cotton swabs on each pin decreases the risk for infection. If the pins are loose, the provider will know how much to tighten the pins and prevent damage to the tissue and bone. Increased redness, heat, and/or drainage at the pin sites can indicate infection leading to osteomyelitis. The patient should never use the fixation device to lift or move the affected leg, due to the risk of injuring and dislocating the fractured bone.
The nurse caring for a client with GBS has identified the priority client problem of decreased mobility for the client. What actions by the nurse are the best? Select all that apply. A. Ask occupational therapy (OT) to help the client with ADLs B. Consult the provider about a PT consult C. Provide the client with information on support groups D. Refer the client to a medical social worker or chaplain E. Work with speech therapy to design a high-protein diet
Answers: A, B, E Improving mobility and strength involves a collaborative assistance of OT, PT, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.
An unconscious patient receiving emergency care following an MVA has a possible SCI. What guidelines for emergency care will be followed? Select all that apply. A. Immobilize the neck using rolled towels or a cervical collar B. The patient will be placed in supine position C. The patient will be placed on a ventilator D. The head of the bead will be elevated E. The patient's head will be secured with a belt or tape secured to the stretcher
Answers: A, B, E In the emergency setting, all patients who have sustained a trauma to the head or spine or are unconscious should be treated as though they have a SCI. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the HOB will be considered AFTER admittance to the hospital.
A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. A. How to use a sign board B. Transfer techniques C. Information about impulse control D. Time adjustment to complete activities E. safety precautions for transferring
Answers: A, B, E The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The patient also might display overcautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement.
Which of the following are manifestations of compartment syndrome in a patient with an external fixation device applied for a fracture of the left tibia and fibula? Select all that apply A. Intense pain when the client's left foot is passively moved B. Capillary refill of 3 seconds on the left toes C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client's report of minimal pain relief following a second dose of opioids
Answers: A, C, D, E Pain during passive movement can indicate pressure from edema, a symptom of ACS. A hard, swollen muscle on the affected extremity indicates edema. Burning and tingling indicates pressure from edema, as does minimal relief from opioids. Capillary refill of 3 seconds is expected.
Who is at risk for ischemic necrosis in patients with musculoskeletal trauma? Select all that apply. A. Patients with compression fractures B. Patient on long-term corticosteroid therapy C. Patients undergoing surgical repair of fractures D. Patients with decreased blood supply
Answers: B, C
A rock climber has sustained an open fracture of the right tibia after a 20 foot fall. The nurse plans to assess the client for which potential complications? Select all that apply. A. Congestive heart failure B. Osteomyelitis C. Fat embolism syndrome D. Acute compartment syndrome E. Urinary tract infection
Answers: B, C, D ACS is a serious condition in which increased pressure with one or more compartments reduces circulation to that area. A fat embolus is when fat globules are released from yellow bone marrow into the bloodstream within 12-48 hours of the injury. Bone infection (osteomyelitis) is most common in open fractures. Congestive heart failure is not a potential complication for this client, but a pulmonary embolism can be caused by venous thromboembolisms, which can be caused by fractures. The client is not at risk for a UTI.
A patient with a SCI is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. A. Modifying the traction weights as needed B. Assessing the patient's skin integrity C. Applying the traction upon admission D. Administering pain medication E. Providing passive range of motion
Answers: B, D, E When caring for a patient in traction, the nurse is responsible for skin care and assessment, assessing pain and administering medication, and providing passive range of motion which prevents contractures. The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device MUST NOT be changed without order of a healthcare provider.
Fracture with multiple fracture lines, splitting the bone into pieces
Comminuted
Break in the entire width of the bone
Complete fracture
Fracture that occurs from a loading force pressing on a callous bone
Compression
Fracture that has not healed within 6 months of injury
Delayed union
Fracture with bone fragments not in alignment
Displaced
Fracture that results when excess strain occurs from recreational or athletic activities
Fatigue (stress)
Fracture that occurs on one side but doesn't extend completely through the bone, occurs most often in children
Greenstick
Fracture with bone wedged inside another fractured fragment
Impacted
Fracture with bone fragments remaining in alignment
Non-displaced
Fracture that occurs at an oblique angle across the bone
Oblique
Fracture that extends through the skin
Open or compound fracture
What are the 5 P's of ACS?
Pain Paralysis Paresthesia Pallor Pulselessness
Fracture often occurring in patient with bone cancer or osteoporosis
Pathological or spontaneous fracture
What medication is prescribed to patients with Myasthenia Gravis?
Pyridostigmine (Mestinon)
Fracture with one fracture line
Simple
Fracture that occurs from a twisting motion and is often from abuse
Spiral
