N430 HESI

How would the nurse describe cardiogenic shock when a family member of a client asks for more information about the condition?

A failure of the circulatory pump

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock?

Bradycardia Hypotension Urinary retention

Which complication would the nurse assess in both clients who have Parkinson disease and clients who have myasthenia gravis?

Difficulty swallowing

Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm?

Hypovolemic

Which type of collaborative action would the nurse anticipate the need to rapidly implement when caring for a client who has a blood pressure of 80/60 mmHg and a heart rate of 120 beats/minute after a motor vehicle accident?

Increase circulating blood volume

Which goal is a priority for a client who is unconscious after a cerebrovascular accident?

Maintaining the airway

Which complication will the nurse anticipate when caring for a client in late hypovolemic shock?

Metabolic acidosis

Which is the priority nursing intervention for a client admitted to the hospital with a cerebrovascular accident?

Monitoring for increased ICP

Which assessment would be the priority for the nurse to complete for the client who has Guillain-Barre syndrome with rapidly ascending paralysis?

Monitoring respiratory status

A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. Which factor would the nurse include in the explanation?

Optic nerve inflammation

Which clinical manifestation would the nurse expect when assessing a client who has cardiogenic shock?

Pallor Agitation Tachycardia Narrow pulse pressure

The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock?

Restlessness

Which statement reflects understanding of sepsis screening requirements by the nurse?

Sepsis mortality is affected greatly by treatments performed in the first 6 hours

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure?

Vomiting Irritability Decreased LOC

Which change in the client's lab results indicates the client is experiencing septic shock?

An increased serum lactate level

A client receiving a blood transfusion reports itching and difficulty breaking. Upon assessment the nurse notes an increased heart rate and low blood pressure. Which type of shock would the nurse suspect the client is experience?

Anaphylactic shock

A client with Guillain-Barre syndrome has been hospitalized for 3 days. Which assessment data would the nurse plan to monitor frequently for this client?

Ascending weakness

When assessing levels of consciousness, which one of the four clients would the nurse identify as having the LOWEST neurological function? a) Eye movement: spontaneous; Motor Response: localizes pain; verbal response: inappropriate words b) EM - Opens on pain; MR - Flaccid; VR - Incomprehensible sounds c) EM - Spontaneous; MR - normal flexion; VR - oriented d) EM - opens on sound; MR - abnormal extension; VR - confused conversation

B

While providing care for a client who sustained a severe head injury in an accident, the nurse observes the client is constantly passing urine and dehydrated. Which condition would the nurse suspect as the cause of the client's condition?

Decreased secretion of antidiuretic hormone

Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)?

Temporary episodes of neurological dysfunction