NEURO FINAL WAGNER

A patient is diagnosed with acute pancreatitis. Which education about the basic mechanism of this disease would the nurse provide? 1. The chemicals being produced by your pancreas are going to work too early and they are damaging the pancreatic tissues. 2. Your pancreas has lost the ability to produce insulin. 3. A major part of your inflammatory system is inhibited. 4. Your blood pressure is elevated because of increased blood flow to your pancreas.

Correct Answer: 1 Rationale 1: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues. Rationale 2: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues. Acute pancreatitis is not caused by the pancreass inability to produce insulin. The activation of kallikrein, and not the inhibition of kallikrein, causes systemic hypotension. Rationale 3: The activation of kallikrein, a major part of the inflammatory system, and not the inhibition of kallikrein, causes systemic hypotension. Rationale 4: The multisystem effects of acute pancreatitis generally result in hypotension, not hypertension.

A patient with acute hepatic dysfunction is having difficulty completing his menu and "can't seem to remember" how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy? 1. I 2. II 3. III 4. IV

Correct Answer: 1 Rationale 1: Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes. Rationale 2: Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place. Rationale 3: In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing. Rationale 4: Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.

The nurse is participating in the use of Ransons criteria to assess a patient with pancreatitis. Which statement reflects a disadvantage of using these criteria? 1. It takes 48 hours for complete assessment. 2. Ransons criteria are not valid for patients over 55. 3. This scoring system is not useful for persons with renal disease. 4. Invasive testing is necessary as part of Ransons criteria.

Correct Answer: 1 Rationale 1: The complete assessment of Ransons criteria requires 48 hours after initial symptoms appear. Rationale 2: Ransons criteria are valid for older patients. Age over 55 increases risk. Rationale 3: There is no indication that these criteria is not valid for those with renal disease. Rationale 4: No invasive testing is necessary for this scoring.

A patient diagnosed with acute pancreatitis is nauseated and frequently vomits. The nurse would assign with nursing diagnosis? 1. Altered Comfort 2. Acute Pain 3. Risk for Injury 4. Risk for Infection

Correct Answer: 1 Rationale 1: The patient is demonstrating nausea and vomiting, which would indicate an alteration in comfort related to stimulation of the vomiting center. Rationale 2: Nausea and vomiting may or may not be associated with acute pain. Rationale 3: In general, nausea and vomiting is not a risk for injury. Risk for injury is related to infection, hemorrhage, or shock. Rationale 4: Nausea and vomiting is not related to risk for infection. Risk for infection is related to peritonitis or abscess.

A pregnant woman is admitted to the high risk maternity unit with HELLP syndrome. The nurse would provide which interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Protect the woman from inadvertent injury. 2. Monitor IV sticks for bleeding. 3. Monitor the woman for development of seizure. 4. Monitor the patient for the development of hypernatremia. 5. Prepare the woman for immediate intubation and mechanical ventilation.

Correct Answer: 1,2,3 Rationale 1: The woman with HELLP syndrome has a low platelet count. She should be protected from injury. Rationale 2: The woman with HELLP syndrome has a low platelet count. Invasive lines should be monitored for bleeding. Rationale 3: HELLP syndrome is associated with preeclampsia. This patient should be monitored for development of seizure, which would indicate development of eclampsia. Rationale 4: Monitoring for hypernatremia is not associated with HELLP syndrome. Rationale 5: There is nothing in the scenario that indicates the woman is not breathing well on her own. Intubation is not necessary.

A patient diagnosed with acute pancreatitis is demonstrating signs of respiratory distress. What physiologic rationale would the nurse explain for this change in respiratory assessment? Standard Text: Select all that apply. 1. Pancreatic enzymes can destroy a component of surfactant. 2. Increase in the size of the abdomen may cause atelectasis. 3. Increased intracranial pressure from pancreatic damage reduces neurological control of respiratory rate and depth. 4. Inflammation of the diaphragm may result in pleural effusion. 5. Lung damage may occur from factors released systemically.

Correct Answer: 1,2,4,5 Rationale 1: Respiratory insufficiency and failure are common complications of acute pancreatitis and are attributed to the release of pancreatic enzyme phospholipase A, which destroys the phospholipid component of surfactant. Rationale 2: The increase in abdominal size resultant from inflammation of tissues may reduce respiratory excursion sufficiently to cause pressure on the lung and atelectasis. Rationale 3: A decreased level of consciousness may change respiratory pattern, but this change is not due to increased intracranial pressure. Rationale 4: Enzyme irritation of the diaphragm may result in pleural effusion, which will cause respiratory distress. Rationale 5: Factors such as trypsin, cytokines, and free-fatty acids are released during pancreatitis and can result in lung damage.

A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. INR greater than 1.5 2. History of alcohol abuse 3. Jaundice 4. Mental status changes 5. Serum glucose greater than 125 mg/dL

Correct Answer: 1,3,4 Rationale 1: By definition, acute renal failure results in an INR greater than 1.5. Rationale 2: Acute liver failure has many etiologies. The nurse should not assume this patient has abused alcohol. Rationale 3: The designation of hyperacute liver failure is based upon the amount of time between onset of jaundice and another finding. Therefore, jaundice exists in this patient. Rationale 4: The designation of hyperacute liver failure is based upon the amount of time between onset of an assessment finding and the development of hepatic encephalopathy. Mental status changes are found in hepatic encephalopathy. Rationale 5: Serum glucose is not a factor in determining the classification of acute liver failure.

The nurse has chosen Ineffective Gas Exchange for a patient with acute pancreatitis. What interventions are indicated for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Administer analgesics as prescribed. 2. Monitor for ileus development. 3. Treat inflammatory response. 4. Ambulate as tolerated. 5. Avoid opioid medications.

Correct Answer: 1,3,4,5 Rationale 1: Ineffective gas exchange can occur because the patient is in pain. Treating pain may allow for deeper and more regular respirations. Rationale 2: Development of ileus is not directly related to ineffective gas exchange. Rationale 3: Inflammatory changes can result in ineffective gas exchange due to thickening of the alveolar membrane. Rationale 4: Ambulation will help the patient mobilize fluids and will help to open airways. Rationale 5: Opioid medications are necessary for the control of pain. They do have depressant effects but should be used as needed for comfort.

A patient with acute pancreatitis begins to demonstrate confusion and agitation. How will the nurse evaluate this finding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Neurological changes are a common finding in acute pancreatitis. 2. Confusion is due to the increases of serum ammonia common in pancreatitis. 3. An acute cerebral vascular accident is imminent and the health care provider should be contacted. 4. The patients intracranial pressure is rising sharply. 5. The patients mental status should be documented using the Glasgow Coma Scale.

Correct Answer: 1,5 Rationale 1: The patient with acute pancreatitis frequently develops an alteration in level of consciousness. Rationale 2: Increased serum ammonia levels are not associated with pancreatic dysfunction but rather hepatic dysfunction. Rationale 3: Confusion and agitation in this patient are not related to an impending acute cerebral vascular accident. Rationale 4: Confusion and agitation in this patient do not indicate increasing intracranial pressure but are probably related to pain and anxiety. Rationale 5: The nurse should use the Glasgow Coma Scale to document current neurological status so that changes can be trended.

A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patients prognosis? 1. This disorder often progresses to multiple organ dysfunction with a poor outcome. 2. This disorder often causes pancreatic edema, which will resolve with good results. 3. Extensive fat and tissue necrosis occurs with this type of pancreatitis. 4. The patient will most likely have irreversible damage to the pancreas.

Correct Answer: 2 Rationale 1: A patient with hemorrhagic pancreatitis has a poor prognosis with the potential to develop multiple organ dysfunction. Rationale 2: Nonhemorrhagic or interstitial acute pancreatitis is a short-term illness characterized by pancreatic edema and little to no necrosis. Inflammation is localized and the condition is reversible with a good prognosis. Rationale 3: Hemorrhagic acute pancreatitis is characterized by extensive fat and tissue necrosis with severe damage to the pancreas.

A 55-year-old female patient is admitted with the diagnosis of acute pancreatitis. The nurse anticipates which treatment to be necessary for this patient? 1. Introduction of medication to reduce high-density lipoprotein level 2. Assessment of gall bladder functioning 3. Encouragement to reduce daily alcohol intake 4. Assessment for hypocalcemia

Correct Answer: 2 Rationale 1: Acute pancreatitis is associated with elevated triglyceride levels and not elevated high-density lipoprotein levels. Rationale 2: Since gallstone-induced pancreatitis is more common in women, assessment of the patients gall bladder functioning should be included in the care of this patient. Rationale 3: Since alcohol-induced acute pancreatitis is more common in men, encouragement to reduce daily alcohol intake would not be indicated for this patient. Rationale 4: Acute pancreatitis is associated with hypercalcemia and not hypocalcemia.

A patient with symptoms of acute pancreatitis is scheduled for an abdominal ultrasound and a CT scan. The ultrasound department is very busy, so the patient is asked to wait. What rationale would the nurse provide for not doing the CT scan first? 1. The ultrasound is the only way to assess the severity of damage to the pancreas. 2. The ultrasound can assess for gallstones as the cause of the pain. 3. Once the patient has had a CT scan the ultrasound must be delayed for at least 72 hours. 4. The CT scan will be done only after the ultrasound has demonstrated that complications such as hemorrhage do not exist.

Correct Answer: 2 Rationale 1: An ultrasound cannot determine the severity of the damage to the pancreas. Rationale 2: An ultrasound on admission can assess for gallstones as the etiology of the pain rather than establishing a diagnosis of acute pancreatitis. If this is the case, the CT scan may not be necessary. Rationale 3: There is no reason why the ultrasound should be delayed if a CT scan has already been done. Rationale 4: The ultrasound cannot diagnose these complications. The CT scan is more specific.

A patient with acute hepatic dysfunction demonstrates slow slurred speech and cold clammy skin. The nurse would collaborate with the primary care provider for treatment of which condition? 1. Cerebral embolism 2. Hypoglycemia 3. Bleeding esophageal varices 4. Increased ammonia level

Correct Answer: 2 Rationale 1: Cerebral embolism is not a common occurrence in acute hepatic dysfunction and is not supported by these assessment findings. Rationale 2: Since liver failure interferes with normal carbohydrate metabolism, the patient may develop hypoglycemia secondary to decreased gluconeogenesis. The patient should be closely monitored for the development of hypoglycemic symptoms which include slow thinking, slurred speech, nervousness, tachycardia, and cold clammy skin. Rationale 3: If esophageal varices exist and begin bleeding the patient will experience hematemesis. Rationale 4: Liver failure can result in increased serum ammonia levels, which will cloud mentation. It will not result in cold clammy skin at the level in which the patient will still be able to speak.

A patient with history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition? 1. The patient has developed gall stones as a result of poor liver function. 2. The patient has portal hypertension with shunting of blood. 3. The NSAID use that caused the patient's chronic liver failure has also resulted in gastritis. 4. The abdominal distention caused by ascites has resulted in reflux esophagitis.

Correct Answer: 2 Rationale 1: Esophageal varices are not associated with gall stones. Rationale 2: Esophageal varices are a complication of portal hypertension. Since the esophageal veins in the lower part of the esophagus are a common collateral flow diversion, any rapid increase in pressure of the engorged veins will lead to an acute hemorrhage. Rationale 3: Gastritis is not associated with esophageal varices. Rationale 4: Esophageal varices are not caused by reflux esophagitis.

A patient with acute pancreatitis is diagnosed with a pseudocyst. Which nursing intervention should be added to this patients plan of care? 1. Monitor urine output. 2. Increase assessment for signs and symptoms of infection. 3. Limit protein intake. 4. Reduce fluid intake.

Correct Answer: 2 Rationale 1: Monitoring urine output is not specific to the care of this patient. Rationale 2: A pancreatic pseudocyst is composed of pancreatic enzymes, necrotic tissue, and possibly blood. Some pseudocysts resolve on their own; however, while they are present, they may become infected or rupture into the peritoneal cavity, which can precipitate chemical peritonitis. Because of this, the nurse should increase assessment for signs and symptoms of infection. Rationale 3: There is no reason to limit the amount of protein this patient is consuming. Rationale 4: There is no reason to limit the amount of fluids this patient is consuming.

A patient with acute pancreatitis has been treated to minimize pancreatic stimulation, but vomiting continues. The nurse would anticipate which intervention? 1. NPO status 2. Placement of a nasogastric tube to intermittent suction 3. Administration of morphine 4. Increased ambulation

Correct Answer: 2 Rationale 1: NPO status is part of resting the GI tract and would already be part of minimizing pancreatic stimulation. Rationale 2: Vomiting should stop when the patient is placed on GI tract rest. If this does not occur placement of a nasogastric tube to intermittent suction is considered. Rationale 3: Drug therapy will include antacids, proton pump inhibitors, or anticholinergics. Rationale 4: Increasing ambulation is not indicated when the patient is vomiting.

A patient reports taking two 500 mg acetaminophen tablets "at least 3 or 4 times a day" to treat muscle pain in his back. What nursing assessment question is priority? 1. "Do you drink plenty of water when you take these pills?" 2. "What other medications do you take?" 3. "Have you had your back reassessed lately?" 4. "What other measures do you take to relieve your back pain?"

Correct Answer: 2 Rationale 1: The patient should drink a full glass of water with these pills, but this is not the priority assessment question. Rationale 2: The nurse should assess this patient for unintended acetaminophen overdose by asking about other medications the patient takes. If these other medications also contain acetaminophen the patient may be in danger of overdose. Rationale 3: The nurse would ask questions to follow up on chronic back pain, but this is not the highest priority. Rationale 4: The nurse should ask about additional pain relief measures and may discover problems such as alcohol use. This question is a priority, but it is not the highest priority.

The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation? 1. "I thought her skin color change was due to going to the indoor tanning booth." 2. "She has been exercising by gathering wild berries and greens for salads." 3. "We went to the mall last week and she got pretty tired while shopping." 4. "She was exposed to influenza last week when she went to visit her sister."

Correct Answer: 2 Rationale 1: There is no association with indoor tanning booths and acute liver failure. Rationale 2: This statement may reveal that the patient has ingested mushrooms that can cause liver toxicity. The nurse should ask additional assessment questions. Rationale 3: Being tired and intolerant of exercise would be expected if the patient was in acute liver failure. Rationale 4: Exposure to influenza is not a significant risk factor for development of acute liver failure.

A patient is admitted to the intensive care unit following lower extremity injury in a motor vehicle accident. The patient has history of chronic renal failure. Which nutritional support would the nurse provide? 1. High fat 2. Moderate protein 3. Fluids only for the first 24 hours 4. Low carbohydrate

Correct Answer: 2 Rationale 1: There is no indication that a high-fat diet is correct for this patient. Rationale 2: This patient needs careful monitoring of protein intake to prevent exacerbation of liver failure. Rationale 3: There is no information in the question to indicate that this patient should be restricted to fluids only. Rationale 4: There is no indication that this patient requires low carbohydrates.

While assessing a patient admitted with acute hepatic dysfunction, the nurse notes abnormal involuntary movements of the patient's hands. How should the nurse document this finding? 1. As seizure activity 2. As asterixis 3. As decorticate posturing 4. As hyperreflexia

Correct Answer: 2 Rationale 1: This abnormal movement does not represent a seizure. Rationale 2: Asterixis, or liver flap, refers to an involuntary tremor that is particularly noted in the hands but may also be seen in the feet and tongue. Rationale 3: Abnormal posturing would affect all four extremities. Rationale 4: There finding represents a tremor, not a reflex.

A patient will be given rifaximin (Xifaxan) to reduce ammonia production by intestinal bacteria. The nurse would add which intervention to this patient's plan of care? 1. Monitor IV site for infiltration. 2. Monitor for development of abdominal cramping. 3. Increase fluids to reduce risk of constipation. 4. Monitor serum potassium levels daily.

Correct Answer: 2 Rationale 1: This medication is given orally. Rationale 2: An adverse effect of ammonia-reducing agents is the development of abdominal cramping. Rationale 3: Diarrhea is the more common adverse reaction from these medications. Rationale 4: There is no indication that serum potassium levels will be affected by this medication.

The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will be included in this patients plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Administer high doses of potassium. 2. Monitor pulmonary arterial wedge pressure. 3. Administer several liters of intravenous fluids in the first few hours of treatment. 4. Administer anticholinergic medication. 5. Monitor central venous pressure.

Correct Answer: 2,3,5 Rationale 1: Administering electrolyte replacements as prescribed would be useful to prevent or treat complications. Which electrolytes and the amount of electrolytes will be guided by laboratory results. High doses of potassium are not likely. Rationale 2: In hypovolemia, the goal is to stabilize the patients hemodynamic status. Monitoring pulmonary wedge pressure will provide valuable information about fluid balance. Rationale 3: Fluid resuscitation generally involves an initial several-liter fluid bolus followed by 250500 mL/hour continuous infusion. Rationale 4: Administering anticholinergic medication may decrease pancreatic stimulation but is not indicated to treat hypovolemia. Rationale 5: Central venous pressure is a standard intervention for monitoring hydration status.

A teenage girl is admitted to the intensive care unit after taking an overdose of acetaminophen. What nursing assessment question is priority? 1. "Did you take the pills on purpose?" 2. "Are you diabetic?" 3. "Could you be pregnant?" 4. "Do you feel at all sick to your stomach?"

Correct Answer: 3 Rationale 1: It is important to determine intent to harm oneself, but this is a question better left until later. Rationale 2: The knowledge of whether or not the patient is diabetic is not essential at this point. Rationale 3: This is an important question and will be followed up by a pregnancy test. Rationale 4: Nausea may occur with acetaminophen overdose, but this is not a priority question.

A patient is diagnosed with subtotal pancreatic necrosis. Which intervention would the nurse include in this patients plan of care? 1. Maintain bedrest. 2. Restrict fluids. 3. Administer proton pump inhibitor. 4. Monitor arterial blood gases.

Correct Answer: 3 Rationale 1: Bedrest is not necessary for this patient. Rationale 2: There is no evidence to suggest this patient should be on a fluid restriction. Rationale 3: Patients with subtotal pancreatic necrosis usually require a proton pump inhibitor on a daily basis as the bicarbonate secretion of the pancreas is severely diminished putting the patient at risk for duodenal ulcer. Therefore, the nurse should administer proton pump inhibitors as prescribed. Rationale 4: Arterial blood gas assessment might help determine the presence of acidosis because of the reduction of bicarbonate secretion of the pancreas but a different intervention is the most important at this time.

A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient's symptoms? 1. A 2. E 3. C 4. A combination of A and D

Correct Answer: 3 Rationale 1: Hepatitis A is transmitted through the fecal-oral route. Tattooing is not considered a risk factor for HAV. Rationale 2: Hepatitis E is transmitted by contaminated water and fecal-oral routes. It is most prevalent in India, China, and Southeast Asia. Rationale 3: Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings. Rationale 4: There is no indication that HAV and HDV are associated with receiving a tattoo.

A patient is admitted with the diagnosis of possible acute pancreatitis. Upon assessment, the nurse notes faint bruising over the patients flank region. How would the nurse report and document this finding? 1. Homans sign 2. Cullens sign 3. Grey Turners sign 4. Chvosteks sign

Correct Answer: 3 Rationale 1: Homans sign is an indicator of the presence of deep vein thrombosis, not acute pancreatitis. Rationale 2: The Cullens sign is a bluish discoloration around the umbilicus. Rationale 3: While assessing the patients integumentary status, the nurse might observe a bluish discoloration over the patients flank region. This discoloration is considered the Grey Turners sign. Rationale 4: Chvosteks sign is seen in hypocalcemia and is characterized by numbness and tingling around the mouth.

A patient comes into the emergency department with complaints of abdominal pain that have become very severe. Which observation would the nurse evaluate as supporting the tentative diagnosis of acute pancreatitis? 1. The patient is most comfortable sitting on side of the bed with arms extended back and legs dangling. 2. The patient is most comfortable lying flat in bed. 3. The patient is most comfortable lying on left side, knees pulled up to the chest. 4. The patient is only comfortable while walking around the perimeter of the room with arms wrapped around the abdomen.

Correct Answer: 3 Rationale 1: Sitting on the side of the bed with the arms extended behind and legs dangling might increase intra-abdominal pressure, which would increase pain. Rationale 2: Even though the pain intensity varies greatly from patient to patient, many patients cannot tolerate lying completely flat in bed. Rationale 3: The classic pattern of pain is described as a sudden onset of sharp, knifelike, twisting and deep, epigastric pain that frequently radiates to the back, and is often associated with nausea and vomiting. The patient may report some degree of relief by assuming a leaning forward or knee/chest position and may report an increase in pain when doing activities that increase abdominal pressure. The kneechest position reduces pressure in the abdomen. Rationale 4: Walking around with the arms wrapped around the abdomen would increase intra-abdominal pressure, which would make the pain of pancreatitis more intense.

A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention? 1. Give the dose slowly over at least 15 minutes. 2. Warn the patient that the medication smells like burning rubber. 3. Give all follow-up doses exactly on time. 4. Ask the patient what he weighs.

Correct Answer: 3 Rationale 1: There is no indication that this medication must be given slowly. Rationale 2: This medication smells like rotten eggs. Rationale 3: It is very important that the remaining 17 doses of NAC be given every 4 hours as directed and on time. Rationale 4: The nurse should weigh the patient, not depend upon an estimated weight.

A patient is being assessed for acute pancreatic dysfunction. Which preparation should the nurse ensure before serum laboratory samples are collected? 1. The patient should be maintained on bedrest for at least 4 hours prior to the samples being drawn. 2. Schedule the serum amylase level to be drawn first. 3. Keep the patient NPO for at least 8 hours before the lipase sample is drawn. 4. Ensure that a serum lipase P level is drawn.

Correct Answer: 3 Rationale 1: There is no reason to maintain the patient on bedrest prior to collecting these serum samples. Rationale 2: There is no reason to draw the serum amylase first. Lipase is a more accurate predictor of pancreatic function. Rationale 3: The pancreas is stimulated to secrete enzymes by the presence of food. If the patient has eaten, the levels will be falsely elevated. Rationale 4: Serum amylase P and not lipase P is used to help rule out non-pancreatic elevations in amylase levels.

The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patient's condition is deteriorating? 1. Sweet odor on the breath 2. Tachycardia 3. Hyperresponsive pupillary responses 4. Change in level of consciousness

Correct Answer: 4 Rationale 1: A sweet odor on the breath is not associated with liver failure. Rationale 2: Bradycardia is a finding associated with Cushing's triad, which indicates increased intracranial pressure. Rationale 3: Pupillary responses typically become sluggish. Rationale 4: In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness.

A patient with acute pancreatitis is demonstrating signs of hypovolemic shock. The nurse will conduct additional assessment for which expected cause of this hypovolemia? 1. Increased urine output 2. Undiagnosed gastrointestinal ulcerations 3. Pulmonary edema 4. Fluid shifts and decreased vascular resistance

Correct Answer: 4 Rationale 1: An increase in urine output will not place a patient into hypovolemic shock in this situation. Rationale 2: Even though hypovolemic shock can be caused by undiagnosed gastrointestinal ulcerations, there is not enough information to support this reason in the patient. Rationale 3: Pulmonary edema would be another symptom of third spacing of fluid being shifted from compartments. Rationale 4: Vasoactive substances, released from damaged pancreatic tissue, are responsible for vasodilation, decreased systemic vascular resistance, and increased permeability of endothelial linings of vessels. As vessels become more porous, intravascular fluids shift into other compartments and into the retroperitoneal cavity, causing hypovolemia, third spacing and hypovolemic shock.

A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding? 1. Serum sodium less than135 mEq/L 2. Hematocrit less than 36% 3. HDL level greater than 40 mg/dL 4. Albumin level lower than 3.5 g/L

Correct Answer: 4 Rationale 1: Hyponatremia is not associated with abdominal ascites. Rationale 2: Hematocrit will generally rise as fluid is shifted out of the circulating system and into the abdomen. Rationale 3: An elevated high density lipoprotein level is not typically associated with ascites. Rationale 4: Ascites, an abnormal collection of fluid in the abdominal cavity, develops from decreased colloid osmotic pressure and portal hypertension. Colloid osmotic pressure decreases as a result of a reduction in albumin. Hypoalbuminemia is caused by the inability of the liver to carry out its usual protein metabolism functions causing a drop in colloid osmotic pressure and shifting fluid from the intravascular compartment into other body compartments.

A patient will have a magnetic resonance cholangiopancreatography (MRCP) to evaluate for pancreatitis. What information would the nurse provide regarding this test? 1. A small plug of tissue will be removed for biopsy. 2. This test is invasive and will require conscious sedation. 3. This test will allow direct visualization of the pancreatic duct. 4. No contrast is used for this test.

Correct Answer: 4 Rationale 1: No tissue is removed in this study. Rationale 2: This test in not invasive. Rationale 3: MRCP uses magnetic resonance imaging, not direct visualization. Rationale 4: No contrast is required for this test.

The nurse is caring for a patient with acute pancreatitis experiencing pain. How would the nurse expect to treat this pain? 1. Acetaminophen 2. NSAIDs 3. Demerol 4. Morphine

Correct Answer: 4 Rationale 1: The pain of acute pancreatitis is not likely to be controlled with acetaminophen. Rationale 2: The pain of acute pancreatitis is not likely to be controlled with NSAIDs. Rationale 3: Meperidine (Demerol) is not considered a drug of choice as its major metabolite can accumulate in the body and is neurotoxic. Rationale 4: Since acute pancreatitis is extremely painful, pain control is needed for comfort and to decrease the secretion of pancreatic enzymes. Fentanyl, morphine, and hydromorphone are effective pain relievers for patients with acute pancreatitis.

A patient in acute liver failure has developed increased intracranial pressure. Hypothermia has been induced. Which nursing intervention should be added to the patient's plan of care? 1. Keep the patient's temperature below 33° C. 2. Monitor the patient for development of frostbite. 3. Stimulate the patient at least every 1 hour to assess for neurological changes. 4. Monitor for the development of infection.

Correct Answer: 4 Rationale 1: The patient's temperature should not be allowed to go below 33° C. Rationale 2: The patient's temperature will not be low enough to development frostbite. Rationale 3: The patient has increased intracranial pressure. Sedation, not stimulation, is indicated. Rationale 4: Induced hypothermia increases risk for infection.

A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should be prepared to administer which products? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Mannitol 2. Antibiotics 3. Albumin 4. Vitamin K 5. Fresh frozen plasma

Correct Answer: 4,5 Rationale 1: Mannitol would be administered for increased cerebral edema, not bleeding. Rationale 2: The patient may require antibiotics, but this is not the immediate priority. Rationale 3: Albumin is not administered to treat GI bleed. Rationale 4: Treatment for an acute gastrointestinal bleed due to acute hepatic dysfunction includes the administration of vitamin K. Rationale 5: Since this patient is actively bleeding the administration of fresh frozen plasma is indicated.

A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is having its desired effect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient's abdominal girth is smaller. 2. The patient has no more oozing from esophageal varices. 3. The patient's hemoglobin has increased. 4. The patient's mentation is clearer. 5. The patient has had three stools in the last 24 hours.

Correct Answer: 4,5 Rationale 1: Reduction in abdominal girth is not the intended effect of administration of lactulose; however, some reduction may occur. Rationale 2: Decrease in oozing from esophageal varices is not the intended effect of administration of lactulose. Rationale 3: Lactulose is not intended to increase the patient's hemoglobin. Rationale 4: Lactulose helps to decrease ammonia, which will result in clearer mentation. Rationale 5: Lactulose, a synthetic disaccharide, helps prevent the absorption of ammonia through the bowel by moving the stool through the intestines more rapidly to prevent bacteria from breaking down. Three to five stools daily is the intended effect.

A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient complains of thirst. 2. The patient has a dry cough. 3. The patient's hemoglobin is elevated. 4. The patient's PT is prolonged. 5. The patient has new onset of confusion.

Correct Answer: 4,5 Rationale 1: Thirst is not a documented effect of acute hepatic failure on any major body system. Rationale 2: Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough. Rationale 3: Elevation of hemoglobin is not an expected effect of acute liver failure. Rationale 4: Within the hematologic system, assessment findings would include impaired coagulation with a prolonged PT. Rationale 5: Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy.

The nurse is monitoring the laboratory values of a patient with acute pancreatic dysfunction. Which values would indicate further assessment is required? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hemoglobin level 13.5 mg/dL 2. Serum sodium level 143 mEq/L 3. Serum potassium level 4.0 mEq/L 4. Serum calcium level 8.0 mg/dL 5. BUN level is 80 mg/dL

Correct Answer: 4,5 Rationale 1: This is a normal hemoglobin level, as would be expected with acute pancreatitis. Rationale 2: This is a normal serum sodium level and does not require additional assessment. Rationale 3: Electrolyte disturbances do occur with acute pancreatitis; however, this is a normal potassium level so no additional assessment is currently required. Rationale 4: Hypocalcemia may develop as a result of fat necrosis because serum calcium migrates to the extravascular space surrounding the pancreas where the fat necrosis is taking place. The nurse should assess the patient further with the serum calcium level of 8.0 mg/dL. Rationale 5: Increased BUN level can have many etiologies. Additional nursing assessment is indicated.

A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue. The nurse would explain this acceleration as due to which pathophysiology? 1. Increased concentration of sodium, chloride, and calcium in the brain cells 2. Reduced ability of the macrophages to reach the site of injury 3. Reduced concentration of magnesium and phosphorus in the brain cells 4. Increased concentration of potassium in the brain cells

Correct Answer: 1 Rationale 1: Increased intracellular concentrations of sodium, chloride, and calcium are due to the lack of oxygen reaching the cerebral tissues. Without oxygen, these electrolytes accumulate leading to toxicity within the mitochondria. This leads to further cerebral tissue death. Rationale 2: Cell death due to ischemia is not related to reduced ability of macrophages to reach the site of tissue injury. Rationale 3: Cell death from ischemia is not related to reduced levels of phosphorus and magnesium in the injured tissue. Rationale 4: Accelerated cerebral tissue death is not due to an increased concentration of potassium in the brain cells.

A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility. Which nursing intervention is indicated? 1. Maintain neutral body position. 2. Turn and reposition every 4 hours. 3. Apply antiembolism stockings. 4. Ensure oxygen saturation level of 92%.

Correct Answer: 1 Rationale 1: A neutral body position will help prevent contractures in that it avoids flexion. Rationale 2: The patient should be turned and repositioned every 2 hours to help prevent contractures. Rationale 3: Applying antiembolism stockings will prevent the immobility complication of deep vein thrombosis development and not prevent contractures. Rationale 4: The patient's oxygen saturation should be maintained at 92% or higher however this will not prevent the complication of contracture.

A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state? 1. Testing indicates that the patient has brain function. 2. The patient has clear breath sounds with no indications of pneumonia. 3. The patient cardiac rhythm strip reveals normal sinus rhythm. 4. The patient's urinary output has remained adequate throughout the coma state.

Correct Answer: 1 Rationale 1: Coma is characterized by the absence of arousal and awareness and may be reversible as long as brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and the coma can be reversed. Rationale 2: While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal. Rationale 3: Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal. Rationale 4: Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function is does not indicate potential for reversal.

A patient is admitted for a lumbar laminectomy. The nurse reinforces teaching that which portion of the vertebra will be removed? 1. Roof of the arch 2. Cartilage inside the vertebra 3. Pedicles that attach the arch to the body 4. Spinous process

Correct Answer: 1 Rationale 1: Each vertebra consists of a body that is anterior and an arch that is posterior. The arch section is composed of two pedicles that attach the arch to the body and two laminae that form the roof of the arch. Rationale 2: Cartilage is not a part of the vertebra. Rationale 3: The pedicles attach the arch to the body of the vertebra. This is not the site of a laminectomy. Rationale 4: The spinous process is located at the rear of the vertebrae. This is not the site of the laminae.

The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever "wake up." The nurse should consider which test when formulating a response to this concern? 1. Evoked potentials 2. CT scan 3. Electroencephalogram 4. Lumbar puncture

Correct Answer: 1 Rationale 1: Evoked potentials are recordings of cerebral electrical impulses generated in response to visual, auditory, or somatosensory stimuli. They are used to assist in the evaluation of the location and extent of brain dysfunction after head injury. Evoked potentials may be useful in predicting coma outcome. Rationale 2: A CT scan can help diagnose structural changes, but does not help predict outcome of a coma. Rationale 3: Electroencephalography allows recording of the electrical activity of the brain using electrodes attached to the scalp but is not used to help predict the outcome of a coma. Rationale 4: Lumbar puncture can help determine cause of coma but does not help predict outcome of coma.

A patient in the intensive care unit continues to seizure after receiving lorazepam. He currently has an intravenous infusion of dextrose 5% and 0.45 normal saline infusing at a rate of 125 mL/hr. The nurse would anticipate providing which medication? 1. Fosphenytoin 2. Phenytoin and diazepam 3. Haloperidol 4. Additional lorazepam

Correct Answer: 1 Rationale 1: If administration of a benzodiazepine is not effective in controlling seizure activity administration of a phenytoin is indicated. Fosphenytoin can be administered quickly and does not cause the same cardiovascular depression as other phenytoins. It is also compatible with dextrose solutions. Rationale 2: Phenytoin is not compatible with dextrose solutions. Rationale 3: Haloperidol is not effective in controlling seizure activity. Rationale 4: If the initial dose of lorazepam is not effective in controlling the seizure an additional medication is indicated.

A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which level four intervention? 1. High-dose barbiturate therapy 2. High-volume intravenous fluids 3. Hyperbaric oxygen therapy 4. Hyperosmolar therapy

Correct Answer: 1 Rationale 1: Medical intervention for the treatment of increased intracranial pressure refractory to all other medical interventions may include the use of high-dose barbiturates. This intervention induces a comatose state and significantly decreases cerebral oxygen requirements. Rationale 2: High-volume intravenous fluid administration would be more likely to increase intracranial pressure. Rationale 3: Hyperbaric oxygen therapy is not a treatment identified to help with refractory increased intracranial pressure. Rationale 4: Hyperosmolar therapy is used as a level two intervention, not to treat refractory increase in intracranial pressure.

Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion? 1. The patient exhibits facial grimacing to painful stimuli but does not withdrawal from the stimuli. 2. There is bilateral absence of deep tendon reflexes. 3. Laboratory results reveal elevation of creatine kinase level. 4. The patient exhibits diffuse weakness.

Correct Answer: 1 Rationale 1: One symptom of critical illness polyneuropathy is the demonstration of a painful stimuli being present, such as facial grimacing, without the ability to withdraw from the stimuli. This is because of a distal loss of pain reception abilities. Rationale 2: Deep tendon reflexes are preserved in critical illness polyneuropathy. Rationale 3: There is no laboratory test to diagnose critical illness polyneuropathy. Electrodiagnostic testing is necessary for diagnosis. Rationale 4: Critical illness polyneuropathy that mainly affects the lower limb nerves. Diffuse weakness is characteristic of critical illness myelopathy.

A patient with spasticity of the upper extremity after a stroke asks why a sling is not used to support the arm. Which rationale should the nurse provide? 1. The use of a sling will reinforce the spasticity and may promote a contracture. 2. A sling will alter your center of balance when standing. 3. The presence of a sling will make it difficult for you to assume responsibility for activities of daily living like dressing. 4. You will not be able to participate in therapy if you get accustomed to your arm being in a sling.

Correct Answer: 1 Rationale 1: Slings limit activity and assist in forming a contracture of the shoulder that will hinder the patient's ability to participate in activities of daily living during and after recovery. Slings will also reinforce muscle spasticity. Rationale 2: Slings do not alter the center of balance. Rationale 3: Difficulty with assuming responsibilities of daily living is not the rationale for avoiding the use of slings. Rationale 4: A sling could be removed for therapy sessions, but this is not the correct information to provide to this patient.

A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient? 1. 50 mm Hg 2. 90 mm Hg 3. 70/40 mm Hg 4. 40/70 mm Hg

Correct Answer: 1 Rationale 1: The cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure. In this patient the cerebral perfusion pressure would be inadequate and intervention is needed. Rationale 2: This calculation is incorrect for the values given. Rationale 3: This calculation is incorrect for the values given. Rationale 4: This calculation is incorrect for the values given.

When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management? 1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain 2. Keeping the blood pressure under control pharmacologically 3. Transferring the patient for rehabilitation as soon as medically stable 4. Reestablishing blood flow to the infarcted area surgically

Correct Answer: 1 Rationale 1: The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover. Rationale 2: The patient's blood pressure should be controlled, but this goal is not global enough to be the primary goal. Rationale 3: Transferring the patient to a long-term care facility as soon as medically stable is a goal for patients to recover enough function to return to their former settings. This is not the primary goal for medical management. Rationale 4: Surgical options are not available for most stroke patients.

A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status? 1. The patient cannot remember where he is. 2. The patient's pupil size is increased. 3. The patient's blood pressure has increased. 4. The patient exhibits decorticate posturing when stimulated.

Correct Answer: 1 Rationale 1: The level of consciousness is the most important indicator of neurological function in the high-acuity patient. Rationale 2: Pupillary changes do occur with neurological damage but are not the earliest signs. Rationale 3: Changes in vital sign can indicate neurological damage, but are not the earliest signs. Rationale 4: Posturing is an important finding associated with neurologic damage, but is not the earliest sign.

A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention? 1. 12 mm Hg 2. 22 mm Hg 3. 25 mm Hg 4. 30 mm Hg

Correct Answer: 1 Rationale 1: The normal intracranial pressure ranges from 0 to 15 mm Hg. Rationale 2: This pressure exceeds normal. Rationale 3: This pressure exceeds normal. Rationale 4: This pressure exceeds normal.

A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage? 1. The patient reports an unusual amount of pain. 2. Muscle spasms are occurring in the patient's right leg. 3. The patient has ataxia. 4. The patient is complaining of vertigo.

Correct Answer: 1 Rationale 1: The spinothalamic tract originates in the spinal cord, crosses over with segments of entry and ascends to the thalamus in the brain. It transmits pain and temperature. The patient with damage to the spinothalamic tract of the spinal cord will manifest an unusual amount of pain. Rationale 2: The corticospinal tract originates in the brain and crosses over in the brainstem to innervate the opposite side of the body. It transmits motor activity, which would be the cause for the muscle spasms in the patient. Rationale 3: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as ataxia. Rationale 4: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as vertigo in the patient.

A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure. The nurse compares measurements to which critical normal value? 1. 50 mm Hg 2. 70 mm Hg 3. 120 mm Hg 4. 30 mm Hg

Correct Answer: 2 Rationale 1: The CPP critical value is higher than 50 mm Hg. Rationale 2: In order to ensure adequate cerebral oxygenation, the cerebral perfusion pressure must be maintained at greater than 70 mm Hg. Rationale 3: CPP of 120 mm Hg is high and will result in a loss of autoregulation. This is not the critical value to which the nurse compares actual measurements. Rationale 4: A CPP of 30 mm Hg is low and will result in loss of autoregulation. This is not the critical value to which the nurse compares actual measurements

A patient being treated for increased intracranial pressure from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient? 1. "We will let this patient rest between his bath and changing his linens." 2. "We are going to bath this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon." 3. "Be certain that we don't raise this patient's head above 10 degrees during his bath." 4. "You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds."

Correct Answer: 1 Rationale 1: When simple activities result in an increase in intracranial pressure it is necessary to space care in such a way to allow the patient's ICP to recover between events. Rationale 2: Stacking care activities will be detrimental to this patient. Rationale 3: The head of the bed should be elevated to 30 degrees to reduce intracranial pressure without compromising cerebral perfusion pressure. Rationale 4: The patient should be suctioned for 10 seconds or less to reduce an increase in intracranial pressure caused by the suctioning.

A patient who injured his cervical spine was first taken to the emergency department of a small hospital where methylprednisolone (MPSS) was started intravenously. The patient has now been transferred to a neurointensive care unit in a large hospital. What interventions would the nurse in the receiving agency include in the plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Assess the patient's breath sounds every 2 hours. 2. Check all stools for blood. 3. Keep the patient NPO. 4. Insert an indwelling urinary catheter so accurate intake and output can be measured. 5. Monitor for the development of hypotension.

Correct Answer: 1,2 Rationale 1: Steroid use is related to increased risk for pneumonia. The nurse should increase surveillance for changes in breath sounds. Rationale 2: Use of steroids increases the patient's risk for gastrointestinal bleeding. The nurse should check all stools, vomitus, or nasogastric drainage for the presence of blood. Rationale 3: Use of steroids does not require the patient to be NPO. Rationale 4: Use of steroids does not signify need for I&O measurement. Rationale 5: Steroid use does not increase risk for hypotension.

A patient with an intraventricular catheter for the assessment of increased intracranial pressure is demonstrating is demonstrating A waves. The nurse would assess for which other findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Decreasing level of consciousness 2. Pupillary changes 3. Posturing 4. Variations in blood pressure 5. Changes in the wave associated with respiration

Correct Answer: 1,2,3 Rationale 1: A waves are clinically significant and typically occur when ICP is elevated. A decreasing level of consciousness may occur with this elevation. Rationale 2: A waves are clinically significant and typically occur when ICP is elevated. Pupillary changes may occur with this elevation. Rationale 3: A waves are clinically significant and typically occur when ICP is elevated. Posturing may occur with this elevation. Rationale 4: C waves occur with variations in blood pressure. Rationale 5: C waves vary according to respiration.

A nurse is preparing to conduct a neurological assessment on a patient who is not suspected for having neurological impairment. Which tests should the nurse perform? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Observation for level of consciousness 2. Checking pupillary response to light 3. Ability to count by serial 7s 4. Assessing the blood pressure 5. Visual acuity

Correct Answer: 1,2,3,4 Rationale 1: Simple testing for level of consciousness includes observing the patient for response to auditory or tactile stimuli. Rationale 2: Simple penlight testing for pupillary response to light is a part of the abbreviated neuro check. Rationale 3: Ability to count by serial 7s is not part of the abbreviated neuro check. Rationale 4: Vital sign assessment is part of the abbreviated neuro check. Rationale 5: Visual acuity is not a part of the abbreviated neuro check.

A patient newly admitted to the intensive care unit reports that he has not been sleeping well at home. The nurse would conduct assessment for which preexisting conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Taking a beta blocker 2. Use of a bronchodilator 3. Snoring 4. Hypothyroidism 5. Alcoholism

Correct Answer: 1,2,3,5 Rationale 1: Beta blockers can be implicated in development of insomnia. Rationale 2: Bronchdilators can be implicated in development of insomnia. Rationale 3: Snoring is associated with sleep apnea, which can cause insomnia. Rationale 4: Hyperthyroidism is a more likely cause of insomnia. Rationale 5: Substance abuse may cause insomnia.

A patient is brought to the hospital after being found in the floor at the bottom of a flight of stairs. The patient has an obvious depressed skull fracture and is bleeding from her right ear. Initially, the nurse assesses the patency of the patient's airway, her breathing, and the rate and rhythm of her pulse. What assessments and questions will be part of the nurse's secondary survey? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "How did the injury occur?" 2. "What care was provided at the site of the injury?" 3. "Has anything like this ever happened before?" 4. Blood pressure measurement will occur. 5. A general systems assessment will occur.

Correct Answer: 1,2,3,5 Rationale 1: The most obvious answer to this question is that the patient fell down the stairs, but this may be an incorrect assumption. The patient may have been injured in some other manner and it was a coincidence that it occurred at the bottom of a flight of stairs. Determining mechanism of injury is a part of the secondary survey. Rationale 2: The nurse should determine what care has already been provided. Rationale 3: Comorbid conditions or previous history is a part of the secondary survey. Rationale 4: Blood pressure measurement is part of the primary survey. Rationale 5: The general systems assessment is part of the secondary survey.

The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow? 1. Oversedation 2. Hypothermia 3. Fever 4. Paralysis

Correct Answer: 3 Rationale 1: Sedation will decrease cerebral blood flow. Rationale 2: Hypothermia will decrease cerebral blood flow. Rationale 3: Fever increases the body's metabolic rate and will increase cerebral blood flow. Rationale 4: Paralysis, often initiated chemically, will decrease cerebral blood flow.

A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in level two interventions to reduce intracranial pressure (ICP) through which uses of this catheter? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Assessing of color of the cerebral spinal fluid 2. Assessing of the amount of cerebral spinal fluid 3. Instillation of hyperosmolar therapy via the catheter 4. Draining CSF 5. Directly monitoring the ICP

Correct Answer: 1,2,4,5 Rationale 1: By assessing the color of the cerebral spinal fluid the nurse can identify variation from normal. These variations may indicate bleeding or infection that would increase ICP. Rationale 2: By using IVC measurements, the nurse can monitor amount of CSF. Rationale 3: Hyperosmolar therapy is not instilled via this catheter. Rationale 4: Therapeutic drainage of CSF via the IVC can reduce ICP. Rationale 5: Insertion of an IVC allows for direct measurement of the ICP.

The nurse is providing community education regarding stroke. Which information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Stroke is caused by interruption of blood flow to the brain. 2. Stroke is the third-leading cause of death in the United States. 3. Stroke usually occurs simultaneously with myocardial infarction. 4. Rapid recognition of stroke symptoms can help decrease poor outcomes. 5. Stroke causes neurological defects.

Correct Answer: 1,2,4,5 Rationale 1: Stroke occurs when a localized area of the brain is not receiving adequate blood flow. The resultant ischemia causes injury to the brain tissue. Rationale 2: Stroke is the third cause of death and a leading cause of disability in the United States. Rationale 3: There is no evidence that stroke and MI generally occur together. Rationale 4: Rapid recognition of stroke symptoms along with rapid intervention can help to decrease poor outcomes from stroke. Rationale 5: Neurological changes and deficits are common when stroke occurs.

The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair. Which nursing interventions are indicated to prevent the onset of orthostatic hypotension? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Apply a binder around the patient's abdomen. 2. Be certain the patient is wearing compression stockings. 3. Swing the patient's legs to the side of the bed in one swift, smooth movement. 4. Gradually raise the head of the bed. 5. Allow the patient to sit on the side of the bed with feet dangling before moving to a chair.

Correct Answer: 1,2,4,5 Rationale 1: The patient should be wearing an abdominal binder when moving from a lying to a sitting position. Rationale 2: The patient should be wearing compression hose prior to moving from a lying to a sitting position. Rationale 3: The patient will likely not tolerate a rapid movement to a sitting position as is indicated by this action. Rationale 4: Chronic peripheral vasodilation causes orthostatic hypotension, particularly for patients with injuries at T6 or above. Chronic vasodilation in combination with a quick position change results in a loss of consciousness. Therefore, initial attempts to mobilize the patient are done slowly. Gradually raising the head of bed is indicated. Rationale 5: Allowing the patient to side on the side of the bed with feet dangling until the blood pressure accommodates a sitting position will help prevent orthostatic hypotension.

The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Blood pressure is consistently above 95 diastolic. 2. The patient has had two recent hospital admissions to treat dehydration. 3. The patient reports drinking a glass of wine with dinner every evening. 4. The patient uses smokeless tobacco. 5. Testing has previously indicated the patient has hypercholesterolemia.

Correct Answer: 1,2,5 Rationale 1: Diastolic hypertension (consistent readings above 95) is a modifiable risk factor for stroke development. Rationale 2: Dehydration may cause dangerous lowering of blood pressure and decrease cerebral perfusion, especially in older patients. This decrease in cerebral perfusion may precipitate stroke. Rationale 3: Moderate alcohol use, such as one glass of wine per day, is not associated with stroke development. Rationale 4: While smoking does increase risk for stroke, the use of smokeless tobacco has not been shown to have the same effect. Rationale 5: Hypercholesterolemia is a risk factor for atherosclerosis in the cerebral vascular beds and increases risk for stroke.

A patient has a spinal cord injury at C6-T1. During his bath the nurse notes piloerection. What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Ask the patient about the presence of a headache. 2. Ignore the occurrence and continue with the bath. 3. Determine if the patient's indwelling urinary catheter tubing is twisted. 4. Lower the head of the patient's bed. 5. Cover the exposed portions of the patient's body with a warm bath blanket.

Correct Answer: 1,3 Rationale 1: Piloerection and headache may be indicators of autonomic dysreflexia. Rationale 2: Piloerection may indicate a serious complication and should not be ignored. Rationale 3: Occlusion of the tubing from an indwelling urinary catheter may result in a full bladder, which is sufficient noxious stimulus to trigger a serious complication. Simply untwisting the tubing and allowing the bladder to drain may reverse this complication. Rationale 4: The head of the bed should be raised. Rationale 5: If this patient is experiencing a complication of spinal cord injury, piloerection is not related to cool environment.

Which goal would the nurse rank as priority for a patient with stroke-related sensory perception alterations? 1. The patient and caregivers will discuss methods to avoid hazards in the environment. 2. The patient will work to increase perception of sensations. 3. The patient will not experience further loss of sensation. 4. The patient will understand the risk of injury related to decreased sensation.

Correct Answer: 1,3 Rationale 1: This patient has decreased ability to perceive environmental hazards, so the patients and caregivers need to discuss methods to avoid injury related to perception loss. Rationale 2: The patient has no control over the loss of sensations, so he or she is not able to work to increase perception. Rationale 3: The patient and the nurse have no control over loss of sensation. This goal is not realistic. Rationale 4: The nurse cannot measure the patient's understanding, so this goal is not correctly written. Even if correctly written, simply understanding the risk is not as important as taking action to avoid risk.

The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Preoxygenate the patient prior to suctioning. 2. Use very low vacuum pressure when suctioning the patient. 3. Limit suction passes to 10 seconds or less. 4. Suction when PaCO2 levels rise above 40 mm Hg. 5. Suction the patient before and after scheduled turns.

Correct Answer: 1,3 Rationale 1: To maintain adequate oxygenation during suctioning, preoxygenation is indicated. Rationale 2: Low vacuum pressure will not adequately remove secretions, making suctioning ineffective or necessary more often. This will not increase oxygenation. Rationale 3: For patients at risk for increased ICP, total suction time should be limited to no more than 10 seconds. Rationale 4: Increased PaCO2 level may or may not be associated with need to suction. Desired PaCO2 level is 35 to 45 mm Hg. Rationale 5: The patient should be suctioned as needed, but nursing activities should be spaced as much as possible. Routine suctioning both before and after scheduled turns is not likely to be necessary and would decrease oxygenation.

A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia? Standard Text: Select all that apply. 1. The confusion cleared when the patient was rehydrated. 2. The patient does not recognize her daughter. 3. The patient's daughter reports that her mother has been becoming increasingly confused over the last 6 months. 4. The patient's mentation was clear yesterday. 5. The patient does not recognize that she is confused.

Correct Answer: 1,4 Rationale 1: Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported. Rationale 2: It is not possible to determine if the inability to recognize familiar people is due to delirium, dementia, or another physiologic cause. Rationale 3: Increasing confusion is more likely to support the diagnosis of dementia. Rationale 4: Delirium is situational, reversible, and acute. Since the patient's mentation was clear yesterday, it is more likely to reflect delirium rather than dementia. Rationale 5: Ability to recognize that one is confused does not differentiate between delirium and dementia.

A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient? 1. If the patient has high blood pressure 2. If the symptoms are still present 3. If this is a recurrent problem 4. If the patient fell

Correct Answer: 2 Rationale 1: Although important, determining if the patient has a history of high blood pressure can be determined at a later time. Rationale 2: Although all of these issues are important in the assessment of the patient, it is essential to determine if the patient still has the symptoms or if they were time limited. If symptoms are no longer present they are still significant as the patient may have experienced a transient ischemic attack. Rationale 3: It is important to discern if the patient has ever experienced these symptoms before, but this is not the most important information. Rationale 4: Assessing if the patient has fallen is not important for the nurse to ask initially.

A patient is diagnosed with bleeding into the cerebellum. The nurse would prepare this patient for which medical intervention? 1. Angioplasty 2. Immediate surgery to remove the blood from the cerebellum 3. Stent placement 4. Aggressive diuretic therapy to dehydrate cerebral tissues

Correct Answer: 2 Rationale 1: Angioplasty is used to reverse neurological deficits caused by artherosclerotic lesions in the cerebral arteries. It is not indicated for cerebellar bleeding. Rationale 2: Cerebellar lesions are critical because a hemorrhage or infarction can rapidly become life threatening by compromising the brainstem. Patients with large hemorrhages or infarctions are more likely to have brainstem compression and an urgent need for surgery. Rationale 3: Stents are placed to hold arteries open. This intervention is not indicated in the face of cerebellar bleeding. Rationale 4: Diuretic therapy will not decrease the compression of brain tissue that will result from cerebellar bleeding.

A patient was admitted this morning after sustaining an acute spinal cord injury. This afternoon his neurological assessment shows some deterioration of function. How would the nurse explain this to the patient's family? 1. "Injured cells release potassium that causes destruction of the covering of nerves in the area injured." 2. "Decreased blood flow increases the size of the affected area." 3. "The body's inflammatory response has caused blood vessels in the area to dilate." 4. "Injury to nerves impairs the body's healing responses."

Correct Answer: 2 Rationale 1: Calcium is released in a spinal cord injury and is responsible for demyelization. Rationale 2: Blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm induced thrombosis. Thrombi in the microcirculation impede blood flow. The zone of ischemia can spread if perfusion to the cord is not restored. Rationale 3: Dilation of vessels would improve blood flow to the region and would not result in deterioration of neurological condition. Rationale 4: This statement is not true.

The nurse is instructing a patient on stroke prevention. Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development? 1. "I have hypertension just like my mom and her family." 2. "Lots of people of my ethnicity suffer strokes." 3. "I have tried several times to quit smoking, but I just can't seem to do it." 4. "It is going to be hard to give up eating red meat and my favorite family meals just to lower my cholesterol."

Correct Answer: 2 Rationale 1: Even familial hypertension can be modified or controlled to help prevent stroke development. Rationale 2: Ethnicity is a nonmodifiable risk factor for the development of stroke. Rationale 3: Smoking cessation is difficult, but achievable and is a modifiable risk factor for stroke development. Rationale 4: Hyperlipidemia is a controllable risk factor for the development of stroke.

A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication? 1. Fosphenytoin 2. Lorazepam 3. Propofol 4. Diazepam

Correct Answer: 2 Rationale 1: Fosphenytoin would be administered if the first line class of drugs was ineffective in controlling the seizure. Rationale 2: Intravenous benzodiazepines are effective in stopping seizures 65-80% of the time. Lorazepam is the treatment of choice over diazepam because it lasts longer. Rationale 3: Propofol could be administered if the first and second line drugs are ineffective in controlling the seizure. Rationale 4: Diazepam is a benzodiazepine that can be administered intravenously; however, it does not last as long as the preferred drug.

An elderly patient is admitted to the intensive care unit with acute respiratory injury from aspiration. The nurse monitors this patient very carefully to avoid onset of polyneuropathy because the patient has history of which disorder? 1. Hypertension 2. Type 2 diabetes mellitus 3. Urinary urgency 4. Congestive heart failure

Correct Answer: 2 Rationale 1: History of hypertension is not known to increase risk for development of polyneuropathy in critically ill patients. Rationale 2: It is believed that tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%. Therefore, the patient with history of type 2 diabetes is at higher risk for developing polyneuropathy when critically ill. Rationale 3: There is no indication that urinary urgency is associated with increased risk of polyneuropathy in critically ill patients. Rationale 4: There is no evidence to suggest that history of congestive heart failure increases risk of polyneuropathy in critically ill patients.

A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use. Before administering this drug the nurse should prepare to manage which patient response? 1. Hypertension 2. Seizure 3. Sudden temperature elevation 4. Bradycardia

Correct Answer: 2 Rationale 1: Hypertension is not the response most likely to occur when flumazenil is administered. Rationale 2: Seizures and delirium are more likely to occur with sudden discontinuation of benzodiazepines which will occur when flumazenil is administered. Rationale 3: Sudden temperature elevation does not occur with administration of flumazenil. Rationale 4: Bradycardia does not occur with administration of flumazenil.

A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area. When assessing this patient, the nurse will expect to find sensory deficits at which anatomical area? 1. Anterior thigh 2. Nipple line 3. Umbilicus 4. Groin

Correct Answer: 2 Rationale 1: Innervation to the anterior thigh is at the 2nd lumbar vertebra. Rationale 2: The nerve root for the 4th thoracic vertebra is approximately at the level of the nipple line. Rationale 3: The nerve root for the umbilical region is the 10th thoracic vertebra. Rationale 4: Innervation to the groin is at the 1st lumbar vertebra.

A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clam shell brace. How would the nurse explain the purpose of this brace? 1. "Wearing this brace will eliminate the need for further surgery." 2. "You need to wear this device to support your surgical site." 3. "This brace will maximize your range of motion." 4. "You need to wear this brace to protect your surgical incision."

Correct Answer: 2 Rationale 1: It is premature to assure the patient that wearing a brace will eliminate need for further surgery. Rationale 2: A clam shell brace after surgery to stabilize a lumbar spinal cord injury is prescribed to specifically support the surgical site. Rationale 3: Stabilization devices do not necessarily maximize the patient's range of motion but rather limit range of motion. Rationale 4: The brace is not prescribed for the purpose of protecting the surgical incision.

A patient suffered an acute T6 spinal cord injury. Family has been told that the patient will likely be paraplegic. However, this morning the patient has limited use of his arms. How should the nurse explain this change? 1. "There must be a second area of fracture higher in the spine." 2. "The spinal cord is probably swollen above the area of original injury." 3. "These changes are due to the low blood pressure he had before he got to the hospital." 4. "This is a sign that he is dehydrated and will go away as we give him more IV fluids."

Correct Answer: 2 Rationale 1: It would be premature to suggest that a second area of injury exists. Rationale 2: In a spinal cord injury, as the cord swells within the bony vertebrae, edema moves up and down the cord. A patient may exhibit symptoms as a result of the edema and not the initial injury. Because edema can extend the level of injury for several cord segments above and below the affected level, the extent of injury may not be determined for several days, until after the cord edema has resolved. Rationale 3: There is no evidence that this change in neurological status is associated with prehospital hypotension. Rationale 4: This change is not likely due to hypovolemia.

A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings? 1. The accident causing this injury occurred several weeks ago. 2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion. 3. There is dilation of the pupils for several hours post injury. 4. There is presence of coma that may last for an extended period of time.

Correct Answer: 2 Rationale 1: Mild diffuse axonal injury generally manifests quickly after the accident. Onset of symptoms weeks after injury is more likely seen in patients with chronic subdural hematoma. Rationale 2: Mild diffuse axonal injury may contribute to post-concussive syndrome experienced by many patients following a brain concussion. Rationale 3: Dilated pupils are not necessarily associated with any degree of diffuse axonal injury. Rationale 4: A long term comatose state is seen in severe diffuse axonal injuries.

A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol? 1. Phenytoin 2. Risperidone 3. Morphine 4. Amiodarone

Correct Answer: 2 Rationale 1: Phenytoin is used to manage seizures. Rationale 2: For patients unable to tolerate haloperidol for delirium, risperidone is an alternative. Rationale 3: Morphine is prescribed to control pain may cause a worsening of delirium. Rationale 4: Amiodarone is a cardiac medication.

The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicated the greatest possibility that this patient is having a stroke? 1. Radicular pain, decreased deep tendon reflexes, loss of bladder control 2. Dysphagia, hemianopsia, hemiparesis 3. Dystonia, dysphagia, dysarthria 4. Paresthesia, priaprism, loss of reflexes

Correct Answer: 2 Rationale 1: Radicular pain, decreased deep tendon reflexes, and loss of bladder control are more likely associated with other neurologic conditions rather than stroke. Rationale 2: The most common cluster of symptoms seen in a stroke is dysphagia, hemianopsia, and hemiparesis. Rationale 3: Dysphagia is common in stroke, but dystonia and dyarthria are not common findings associated with stroke. Rationale 4: The patient having stroke may have some paresthesia, but priapism and loss of reflexes are not common initial findings.

A patient being treated for a traumatic brain injury for 3 days begins to seize. Which intervention is the nurse's priority? 1. Administer fosphenytoin (Cerebyx) 4 mg per kg of patient body weight. 2. Keep the patient safe and maintain the airway. 3. Lower the head of the bed. 4. Initiate a recording of the patient's cardiac rhythm.

Correct Answer: 2 Rationale 1: The first medication administered is more likely to be a benzodiazepine. Medication administration is not the highest priority. Rationale 2: Priorities for the care of a patient with a traumatic brain injury that begins to demonstrate seizure activity include keeping the patient safe and maintain airway, breathing, and circulation. Rationale 3: Lowering the head of the bed may or may not be indicated and is not the priority intervention. Rationale 4: Seizure activity will interfere with an accurate recording of the patient's cardiac rhythm.

A patient was the unrestrained driver of a car that was struck head on by another vehicle. During initial assessment the nurse observes another nurse using supraorbital pressure to assess for response. What nursing intervention is indicated? 1. Hold the patient's head still so that the test will be valid. 2. Stop the procedure. 3. Ask the nurse to repeat the procedure on the other orbit. 4. Document the response as 1+, 2+, 3+, or 4+.

Correct Answer: 2 Rationale 1: The nurse should not attempt to hold the patient's head still. Rationale 2: Since this patient is at high risk for facial fractures, supraorbital pressure should not be used. Rationale 3: The procedure should not be repeated. Rationale 4: The nurse should intervene in a different manner.

A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure. The patient is confused and occasionally combative. His wife expresses concern about how to tell their two young sons. Which nursing diagnosis will guide initial selection of nursing interventions? 1. Ineffective Breathing Pattern 2. Decreased Intracranial Adaptive Capacity 3. Impaired Physical Mobility 4. Risk for Aspiration

Correct Answer: 2 Rationale 1: There is no assessment information that indicates this patient's breathing pattern is altered. Rationale 2: Increased ICP is a result of decreased ability of the intracranial protective mechanisms to compensate for the increase in brain volume caused by the presence of a mass. Rationale 3: There is no information given that supports the nursing diagnosis of Impaired Mobility. Rationale 4: There is no current evidence that this patient is at risk for aspiration.

A patient in the intensive care unit has pulled out his peripheral intravenous line twice and continually picks at his abdominal dressing. How should the nurse describe this behavior? 1. As hyperactive dementia 2. As hyperactive delirium 3. As hypoactive delirium 4. As mixed dementia

Correct Answer: 2 Rationale 1: There is no indication that this patient has dementia. Rationale 2: Hyperactive delirium, also referred to as ICU psychosis, is characterized by agitation, restlessness, and "picking" at monitoring, feeding, or intravenous devices. Rationale 3: Hypoactive delirium is characterized by lethargy rather than agitation, withdrawal, flat affect, apathy, and decreased responsiveness. Rationale 4: There is no indication that this patient suffers from dementia.

The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention? 1. Monitor urine output. 2. Provide eye care. 3. Move the patient as little as possible. 4. Provide mouth care.

Correct Answer: 2 Rationale 1: Urine output should be monitored for all critically ill patients. This monitoring is not specific to patients under neuromuscular block. Rationale 2: Nursing care of a patient receiving a neuromuscular blocking agent should include prophylactic eye care. The nurse should keep the eyes closed and covered with a soft eye pad and use eye lubricants or artificial tears. Rationale 3: The patient receiving neuromuscular blockage will be unable to move self. The nurse must intervene with actions to prevent muscle contractures and skin breakdown. Rationale 4: Mouth care is an essential component of the care of all critically ill patients.

A patient is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient is taking a sulfa drug for urinary tract infection. 2. The patient has a bluish discoloration behind his ear. 3. The patient's nose is running. 4. The patient's smile is crooked. 5. The patient's tongue is lacerated.

Correct Answer: 2,3,4 Rationale 1: Medication history is not the most important information during emergent assessment. Rationale 2: Mastoid ecchymosis or "Battle's sign" can indicate basilar skull fracture. This assessment requires immediate attention. Rationale 3: The fluid in the patient's nose may be cerebral spinal fluid, not mucous. This is an important assessment of basilar skull fracture. Rationale 4: Facial nerve paralysis may indicate basilar skull fracture. Rationale 5: Tongue laceration is important, but is not an emergent problem.

A nurse is assisting with a patient's oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Prepare for oculocephalic testing to be done after oculovestibular testing. 2. Ensure that cervical spine injury has been ruled out. 3. Obtain cold water and a syringe 4. Be certain there is no perforation of the tympanic membrane in the side being tested. 5. Tell the patient he will be asked to report any feeling of numbness or vertigo.

Correct Answer: 2,3,4 Rationale 1: Patients with an absent oculocephalic reflex may have a normal oculovestibular reflex, so testing for oculovestibular reflex should follow oculocephalic reflex. Rationale 2: Oculocephalic testing requires moving the patient's head from side-to-side, so it should not be performed until the cervical spine is cleared of injury. Rationale 3: Oculovestibular reflex testing includes injecting cold water into the patient's ear. Rationale 4: Since oculovestibular testing includes placing water in the ear, it is contraindicated if there is a perforation or tear in the tympanic membrane. Rationale 5: Oculovestibular and oculocephalic testing is done on patients with suspected brain stem depression. The patients are not conscious.

A nurse is assisting with a patient's oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing? Standard Text: Select all that apply. 1. Prepare for oculocephalic testing to be done after oculovestibular testing. 2. Ensure that cervical spine injury has been ruled out. 3. Obtain cold water and a syringe 4. Be certain there is no perforation of the tympanic membrane in the side being tested. 5. Tell the patient he will be asked to report any feeling of numbness or vertigo.

Correct Answer: 2,3,4 Rationale 1: Patients with an absent oculocephalic reflex may have a normal oculovestibular reflex, so testing for oculovestibular reflex should follow oculocephalic reflex. Rationale 2: Oculocephalic testing requires moving the patient's head from side-to-side, so it should not be performed until the cervical spine is cleared of injury. Rationale 3: Oculovestibular reflex testing includes injecting cold water into the patient's ear. Rationale 4: Since oculovestibular testing includes placing water in the ear, it is contraindicated if there is a perforation or tear in the tympanic membrane. Rationale 5: Oculovestibular and oculocephalic testing is done on patients with suspected brain stem depression. The patients are not conscious.

Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Position the patient supine on the left side. 2. Teach the patient to hold his head for support when changing positions. 3. Conduct frequent assessments for facial drooping or tongue deviation. 4. Monitor blood pressure level frequently. 5. Perform frequent tracheostomy care.

Correct Answer: 2,3,4 Rationale 1: This patient should be positioned on the right side with the head of the bed elevated 30 degrees to reduce operative site edema. Rationale 2: Support prevents additional tension on the operative side which could result in bleeding and hematoma formation. The nurse should support the patient's head when assisting with position changes and should teach the patient to do so for independent position changes. Rationale 3: Temporary deficits in cranial nerve function may indicate stretching of these nerves. The nurse should assess for these changes that may indicate need for further intervention. Rationale 4: Patients who have this procedure are at risk for blood pressure instability due to disruption of the carotid sinus. Rationale 5: This procedure does not require placement of a tracheostomy.

A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated? Standard Text: Select all that apply. 1. Hold the patient as still as possible to prevent tissue damage. 2. Roll the patient to the side if possible. 3. Place a padded tongue blade in the patient's mouth. 4. Time the seizure from beginning to end. 5. Call the rapid response team.

Correct Answer: 2,4 Rationale 1: The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still. Rationale 2: Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration. Rationale 3: No attempt to place anything in the patient's mouth should be made. Rationale 4: Length of seizure is important assessment information that can be collected by the nurse. Rationale 5: The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure.

A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra. The nurse will expect to find which deep tendon reflexes affected by this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Supinator 2. Patellar 3. Triceps 4. Biceps 5. Achilles

Correct Answer: 2,5 Rationale 1: The supinator reflex originates at the 6th cervical vertebra, which is above the area injured. Rationale 2: The patellar reflex originates at the 3rd lumbar vertebra. The patient has an injury at the 1st and 2nd thoracic vertebra, which means reflexes below this region will be affected. Rationale 3: The triceps reflex originates at the 7th cervical vertebra, which is above the injured area. Rationale 4: The biceps reflex originates at the 5th cervical vertebra which is above the injured area. Rationale 5: The Achilles reflex originates at S1. The patient has an injury at the 1st and 2nd thoracic vertebra which means reflexes below this region will be affected.

A patient diagnosed with several fractured vertebra is having surgical stabilization. The nurse would reinforce which information about this surgery? 1. "You will be required to wear a hard cervical collar for several months after the surgery." 2. "After surgery you will be fitted for a halo device." 3. "The fusion generally requires insertion of rods to stabilize your spine internally." 4. "This is the first of a series of surgeries you will require."

Correct Answer: 3 Rationale 1: A hard cervical collar is a manual fixation device. Whether this device is required and how long it is required is variable and is likely not known prior to surgery. Rationale 2: The patient may or may not require a halo device. Rationale 3: Surgery is reserved for patients not sufficiently aligned with manual stabilization. Typically, spinal segments are fused, spinal canal is decompressed, and rods are inserted to stabilize thoracic spinal injuries. Rationale 4: There is no indication that this patient will require a series of surgeries.

A nurse is monitoring a patient's Glasgow Coma Scale (GSC). At which point would the nurse document that the patient is comatose? 1. 11 2. 15 3. 7 4. 9

Correct Answer: 3 Rationale 1: A score of 11 indicates some impairment, but does not indicate coma. Rationale 2: A GCS of 15 is normal. Rationale 3: A score of 7 or less indicates a significant alteration in the level of consciousness and the development of coma. Rationale 4: A GCS score of 9 indicates significant neurological changes, but does not indicate coma.

A patient who was in a coma for one week after surgery is unable to tell the nurse where he lives or what he did for a living. The nurse evaluates this condition as suggesting which change resulting from the coma? 1. The patient now has a learning deficit. 2. The patient has instability of emotions. 3. The patient's cognition is impaired. 4. The patient was near brain death before the coma resolved.

Correct Answer: 3 Rationale 1: The patient should be able to remember basic facts about his life. He would not have to relearn these facts, so this scenario does not indicate that a learning deficit exists. Rationale 2: There is no indication that the patient has responded emotionally to his change in mental status. Rationale 3: Inability to remember basic facts indicates that the patient's cognition is impaired. Rationale 4: Simple inability to remember facts cannot be construed to mean that patient was near brain death. This might have been the case, but there are not enough facts to support this option.

The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable? 1. There will be an increase in the blood flow to the brain. 2. There is a decrease in the blood-brain barrier. 3. There must be a decrease in another of the intracranial compartments. 4. There will be an increase in the production of cerebrospinal fluid.

Correct Answer: 3 Rationale 1: Blood flow to the brain would decrease as more space is taken up by the brain. Rationale 2: The blood-brain barrier does not increase or decrease in response to changes in the brain. Rationale 3: The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro-Kellie hypothesis states that as the content of one of the intrancranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments. Rationale 4: An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault.

A patient is admitted to the intensive care unit accompanied by a family member who says, "He suddenly started acting funny and couldn't remember where he was." The nurse would anticipate that first assessment efforts would focus on which condition? 1. Hypovolemic shock 2. Cerebral infection 3. Ischemic stroke 4. Drug overdose

Correct Answer: 3 Rationale 1: Hypovolemic shock is not the most common cause of changes in mentation in patients admitted to the ICU. Rationale 2: Cerebral infection is not the most common cause of changes in mentation in patients admitted to the ICU. Rationale 3: Even though there are many causes of impaired mentation in patients who have not sustained a head injury, ischemic stroke has been found to be the most frequent cause of impaired mentation on admission to the intensive care unit. The patient should be assessed first for an ischemic stroke. Rationale 4: Drug overdose is not the most common cause of changes in mentation in patients admitted to the ICU.

A patient in the critical care unit has a seizure that was determined to be caused by a low blood glucose level. The patient's blood glucose level is currently normal. Which additional intervention should be implemented to prevent future seizure activity in this patient? 1. Administer valium orally twice each day. 2. Establish a low-dose continuous phenytoin infusion. 3. Increase the frequency of blood glucose assessment. 4. Frequently monitor brain wave activity.

Correct Answer: 3 Rationale 1: If the cause of the seizure is identified and corrected, pharmacologic intervention for seizure prevention is often not indicated. Rationale 2: Since the cause of the seizure was identified and corrected pharmacological intervention is often not necessary. Rationale 3: The cause of the patient's seizure has been identified as low blood glucose. The best plan of action is to prevent low blood glucose. An effective intervention is to increase frequency of blood glucose measurement to ensure early intervention for hypoglycemia. Rationale 4: The cause of the patient's seizure has been identified and corrected. It is not necessary to undertake frequent monitoring of brain wave activity.

A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Insert a nasogastric tube for nutritional support. 2. Monitor for renal stone formation. 3. Monitor for deterioration of neurological status. 4. Reposition every 15 minutes.

Correct Answer: 3 Rationale 1: Insertion of a nasogastric tube can cause injury and should be avoided in this patient. Rationale 2: Renal stone formation is not a complication of this medication. Rationale 3: Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation. Rationale 4: Frequent moving can increase the risk of bleeding therefore the patient should not be repositioned every 15 minutes.

A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse? 1. Document the presence of decorticate posturing. 2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading. 3. Assess the position of the patient's arms. 4. Administer intravenous sedation as quickly as possible after access is obtained.

Correct Answer: 3 Rationale 1: It is not possible to assess decorticate posturing from this scenario. Rationale 2: It is important to gain IV access for this patient. Posturing to noxious stimuli indicates brain damage. Blood pressure is not pertinent at this time. Rationale 3: The nurse should assess the position of the patient's arms to determine if decorticate or decerebrate posturing is present. Rationale 4: Administering sedation is not indicated at this time as assessment is continuing.

Diagnostic testing reveals that a patient has areas of cerebral focal infarctions. The nurse plans care with the realization that which outcome is likely? 1. The patient will likely deteriorate into multiple system organ failure. 2. These areas of ischemia will likely extend into the brainstem. 3. The patient's symptoms will likely resolve with treatment. 4. The patient's symptoms will progress rapidly.

Correct Answer: 3 Rationale 1: Multiple system organ failure is not the most likely outcome for this patient. Rationale 2: Extension of these ischemic areas into the brainstem is not the most likely scenario. Rationale 3: In focal ischemia there is some degree of collateral circulation that remains. This allows for the survival of neurons and for reversal of neuronal damage after periods of ischemia. Focal ischemia is treatable because of the potential for recovery therefore the patient's symptoms will most likely resolve with treatment. Rationale 4: There is no indication that this patient's symptoms will progress rapidly.

A patient is admitted with a fractured mandible and several fractured ribs. Which priority intervention would the nurse anticipate? 1. Providing pain medication 2. Determining lung function by chest x-ray 3. Maintaining spinal cord injury precautions 4. Stabilizing the rib fractures

Correct Answer: 3 Rationale 1: Provision of pain medication is indicated for this patient, but it is not the highest priority. Rationale 2: It is important to determine the status of this patient's lung function but this is not the intervention of highest priority. Rationale 3: Since a spinal cord injury should be suspected in a patient with maxillofacial injury and clavicle or upper rib fractures, the patient should be maintained on spinal cord injury precautions until the injury has been ruled out. Rationale 4: It is important to stabilize rib fractures, but this is not the intervention of highest priority.

Following a stroke a patient is diagnosed with expressive aphasia. What nursing intervention is indicated? 1. Speak slowly and face the patient directly when speaking. 2. Speak at a slightly louder volume. 3. Watch the patient carefully for behavioral clues. 4. Decrease environmental stimuli before attempting to communicate with the patient.

Correct Answer: 3 Rationale 1: The patient with expressive aphasia can understand speech, so this action is not necessary. Rationale 2: The patient with expressive aphasia can understand speech, so it is not necessary to speak at a louder volume. Rationale 3: The patient with expressive aphasia cannot write or use language. The nurse should observe for behavioral clues to the patient's needs. Rationale 4: The patient with expressive aphasia can understand speech, so decreasing environmental stimuli is not necessary for the purpose of communication.

A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting. Which interventions would the nurse include in this patient's plan of care? 1. Restrict fluids. 2. Restrict sodium. 3. Monitor intravenous normal saline administration. 4. Provide potassium chloride intravenous replacements.

Correct Answer: 3 Rationale 1: The patient's fluids should not be restricted since this will exacerbate the hypovolemia characteristic of this disorder. Rationale 2: The patient should not be on a sodium restriction. Rationale 3: Cerebral salt wasting is a state of hypovolemia so the patient should be treated with salt replacement via intravenous saline and oral salt tablets. Rationale 4: Potassium replacements are not indicated in the treatment of this complication.

A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention? 1. Culture the patient's urine. 2. Contact the primary health care provider. 3. Administer the prn antipyretic. 4. Have the patient cough and deep breath more frequently.

Correct Answer: 3 Rationale 1: Urinary tract infection will cause increased temperature and this may be a necessary intervention. It is not, however, the primary intervention. Rationale 2: It is important to keep the primary health care provider apprised of the patient's condition, but this is not the primary intervention. Rationale 3: Hyperthermia will increase cerebral metabolic rates, which will increase cerebral oxygen demands. The patient with a temperature should be provided with antipyretics or other measures to cool the body and reduce the temperature. Rationale 4: Implementing pulmonary hygiene activities will not reduce the patient's body temperature.

A patient with seizure activity is receiving intravenous phenytoin (Dilantin). Which nursing interventions are indicated? Standard Text: Select all that apply. 1. Assess deep tendon reflexes. 2. Keep blood glucose level within normal limits. 3. Monitor injection site frequently. 4. Turn and reposition every hour. 5. Monitor for the development of hypotension.

Correct Answer: 3,5 Rationale 1: Assessment of deep tendon reflexes is not a particular intervention necessary for the patient receiving phenytoin. Rationale 2: Phenytoin does not adversely affect blood glucose levels. Rationale 3: Infiltration of phenytoin will cause tissue vesication and necrosis. The nurse must increase frequency of intravenous site assessment. Rationale 4: There is no need to increase frequency of repositioning when patients are receiving phenytoin. Rationale 5: Phenytoin contains propylene glycol which can cause cardiac suppression. Cardiac suppression can be evidenced by the development of hypotension.

A patient had a stroke which resulted in Broca's aphasia. What instructions should the nurse provide when teaching the family how to communicate with this patient? Standard Text: Select all that apply. 1. Speak slowly and loudly to the patient. 2. Use paper and pencil for all communication. 3. Ask the patient "yes-no" questions. 4. Anticipate the patient's answers and finish questions and sentences. 5. Give the patient time to search for words.

Correct Answer: 3,5 Rationale 1: Patients who are aphasic often complain that people shout at them as if they cannot hear. A hearing deficit is not a part of Broca's aphasia and speaking loudly is not indicated. Rationale 2: Writing ability may also be impaired with Broca's aphasia. Rationale 3: The patient with Broca's aphasia is able to comprehend speech, but has difficulty responding verbally. Asking "yes-no" questions allows the patient to respond nonverbally. Rationale 4: The patient with Broca's aphasia may retain some speech. It is not helpful, however, for others to complete the patient's questions or sentences. Rationale 5: Allowing the patient time to search for words may result in adequate expression of needs. It may also help the patient improve word finding, which would improve speech.

The admission orders for a patient with traumatic brain injury say to keep the patient's head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient's head is supported on two pillows. 2. The head of the patient's bed is elevated to 20 degrees. 3. The patient's hips are flexed at less than 90 degrees. 4. The neck is in the patient's position of comfort, which is rotated to the left. 5. The patient is facing forward.

Correct Answer: 3,5 Rationale 1: Placing the head on two pillows flexes the neck which violates the idea of a "neutral" position. Rationale 2: Typically the head of the patient's bed should be elevated to 30 degrees. Rationale 3: Hip flexion of greater than 90 degrees should be avoided. Rationale 4: The neck should not be rotated. Rationale 5: Neutral positioning for the head and neck is a forward facing position.

The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient's pupils to be pinpoint and nonreactive to light. The nurse takes into consideration that this finding can be due to which situations? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient was given atropine sulfate for bradycardia. 2. The patient has increased blood glucose. 3. The patient may have taken an opioid drug overdose. 4. The patient has sustained compression of the oculomotor nerve. 5. The patient has sustained damage to the pons.

Correct Answer: 3,5 Rationale 1: Recent administration of atropine sulfate leads to dilated pupils. Rationale 2: Metabolic disorders cause small but reactive pupils. Rationale 3: Opiod drug overdose will result in pinpoint, nonreactive pupils. Rationale 4: Compression of the oculomotor nerve causes a unilateral fixed and dilated pupil. Rationale 5: Damages to the pons will result in fixed and pinpoint pupils.

A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family? 1. CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain. 2. The CT scan will evaluate how much brain swelling is associated with this stroke. 3. The CT scan will pinpoint the exact area of the brain affected by the stroke. 4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke.

Correct Answer: 4 Rationale 1: A CT alone will not determine the effectiveness of cerebral circulation. Rationale 2: CT scans cannot determine the extent of brain swelling. Rationale 3: CT scans cannot pinpoint the exact area of the brain affected by stroke, but can help to establish the anatomical region in which the stroke occurred. Rationale 4: A CT scan will be used to rule out a hemorrhagic stroke from an ischemic stroke especially if thrombolytic therapy is being considered and to determine any areas of localized hematoma formation as a result of a hemorrhage.

A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic "about 6 weeks ago." The nurse would ask additional assessment questions regarding which condition? 1. Acute subdural hematoma 2. Subacute subdural hematoma 3. Epidural hematoma 4. Chronic subdural hematoma

Correct Answer: 4 Rationale 1: An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern. Rationale 2: Subacute subdural hematoma occurs 48 hours to 2 weeks from injury so this is an unlikely injury pattern. Rationale 3: With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness. Rationale 4: There are three categories of subdural hematoma, based on time of onset of symptoms. Chronic hematoma develops greater than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse would have highest concern regarding a chronic subdural hematoma.

It is suspected that a patient admitted with spinal cord injury has severe cord injury. The nurse would prepare the patient for which diagnostic test to determine the extent of this edema? 1. Angiography 2. Somatosensory-evoked potentials 3. CT scan 4. MRI

Correct Answer: 4 Rationale 1: Angiography is useful for patients with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Rationale 2: Somatosensory-evoked potentials are used to establish a functional prognosis after resolution of spinal cord edema. Rationale 3: CT scans are not the most sensitive tests for determination of cord edema. Rationale 4: The MRI has greater sensitivity than a CT scan for diagnosing contusions, hematomas, and edema. The diagnostic test that would be the most helpful for this patient would be the MRI.

A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury? 1. Ankylosing spondylitis 2. Axial loading 3. Hyperflexion 4. Hyperextension

Correct Answer: 4 Rationale 1: Ankylosing spondylitis can cause a nontraumatic hyperextension injury. Rationale 2: Axial loading injury, or compression fracture, is caused by a vertical force along the spinal cord and is seen after diving into shallow water or jumping from tall heights and landing on the feet or buttocks. Rationale 3: Hyperflexion injury is most often caused by a sudden deceleration of the motion of the head or a head-on collision. Rationale 4: Hyperextension injuries are caused by a forward and backward motion of the head as seen in rear-end collisions. With this injury, the anterior ligaments are torn and the spinal cord is stretched. A mild form of hyperextension injury is the whiplash injury.

A patient who sustained a traumatic brain injury is being sent for a CT scan. Which nursing statements would help the patient's spouse understand the rationale for a CT scan rather than an MRI? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "CT scans are easier for patients with head injuries because movement is allowed." 2. "We can get results from a CT scan quicker than from an MRI." 3. "MRIs are more costly so the least expensive test is always done first." 4. "CT scans are noninvasive." 5. "CT scans show more detail than an MRI."

Correct Answer: 4 Rationale 1: CT scans do not necessarily provide more patient movement while the test is being conducted. Rationale 2: The CT scan is the test of choice with head injury patients because MRIs take longer. Rationale 3: MRIs are typically more expensive, but the nurse should not use this as a rationale for the choice when talking with the family. Rationale 4: CT scans are noninvasive. Rationale 5: MRIs show more tissue detail than do CT scans.

A patient is admitted with a traumatic brain injury. The nurse would anticipate participating in interventions toward which immediate goal? 1. Reducing cerebral swelling 2. Confining inflammation to one area 3. Supporting absorption of debris from neuronal death 4. Limiting ischemic tissue injury

Correct Answer: 4 Rationale 1: Cerebral swelling can cause secondary injury, but this is not the immediate goal. Rationale 2: Inflammation can cause secondary injury but this is not the immediate goal when caring for someone with TBI. Rationale 3: Eventually the body will rid itself for debris from death of any cells, but this is not the immediate goal. Rationale 4: The first goal in treating traumatic brain injury is to limit the primary ischemic tissue injury by aggressive prevention and treatment of hypoxia and hypotension. If efforts to meet this goal are successful, cerebral swelling neuronal death and cerebral inflammation can be limited as well.

A patient is diagnosed with central cord syndrome. Which assessment finding would the nurse anticipate from this injury? 1. Complete paralysis of lower extremities 2. Loss of bladder and bowel function 3. Motor function intact in upper extremities 4. Variable motor function in lower extremities

Correct Answer: 4 Rationale 1: Complete paralysis of lower extremities does not result from central cord syndrome. Rationale 2: Patients with central cord injury typically retain some bladder and bowel function. Rationale 3: The upper extremities will demonstrate spastic paralysis and not an intact upper extremity motor status. Rationale 4: In central cord syndrome the patient will demonstrate variable motor function of the lower extremities.

Which assessment finding supports the nursing diagnosis of Risk for Aspiration in a patient with a cerebral vascular accident? 1. Eating only foods on one side of the tray 2. Refusal to allow the nurse to assist with feeding 3. Absence of interest in eating or drinking 4. Continuous clearing of the throat

Correct Answer: 4 Rationale 1: Eating foods only on one side of a tray represents a sensory perceptual problem related to the stroke. Rationale 2: Refusal to allow the nurse to assist with feeding indicates psychosocial changes associated with stroke. Rationale 3: Absence of interest in eating indicates an altered mood, such as depression, related to an altered neurological or health status. Rationale 4: Continuous clearing of the throat or coughing while eating or drinking indicates that food or fluids are entering the trachea or pooling in the back of the throat. The nurse needs to stop feeding when this is noted and speech therapy should be consulted for a swallowing exam.

A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient? 1. Electrolyte replacements 2. Maintain adequate fluid volume. 3. Supporting nutritional needs 4. Maintain stable cerebral perfusion pressure.

Correct Answer: 4 Rationale 1: Electrolyte management is important to patients with head injury but is not the intervention of highest priority. Rationale 2: Fluid volume management is important when caring for patients with brain injury, but is not the highest priority. Rationale 3: Support of nutritional needs is important for all patients, but is not the intervention of highest priority for patients with brain injury. Rationale 4: Since diffuse head injuries are not limited to a localized area, this makes them more difficult to detect and treat. Management in the acute care phase includes diligent and frequent neurological assessments and pain management. When moderate-to-severe injury is present, priority management includes interventions to lower intracranial pressure, increase cerebral perfusion pressure, and stabilize vital signs, which all contribute to an improved outcome.

When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor? 1. Hypertension 2. Use of anticoagulants 3. History of atherosclerosis of cerebral arteries 4. Atrial fibrillation

Correct Answer: 4 Rationale 1: Hypertension is more likely associated with thrombotic stroke. Rationale 2: Use of anticoagulants and hypertension together are associated with hemorrhagic cerebral vascular accidents. Rationale 3: Atherosclerosis of cerebral arteries is associated with ischemic stroke. Rationale 4: Atrial fibrillation, in addition to endocarditis, rheumatic heart disease, and recent myocardial infarction, are the most common causes of embolic cerebral vascular accidents.

A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury? 1. As life threatening 2. As stable 3. As minor 4. As unstable

Correct Answer: 4 Rationale 1: In itself, this injury is not life threatening. If secondary damage occurs, it could become life threatening. Rationale 2: This injury is significant and would not be considered stable. Rationale 3: Damage to two columns of three vertebrae is not a minor injury. Rationale 4: The spine is conceptualized as having three columns: an anterior column that includes the anterior part of the vertebral body, a middle column that houses the posterior wall of the vertebral body, and a posterior column that includes the vertebral arch. If two or more of these columns are damaged, the injury is considered to be unstable. The patient has an unstable spinal cord injury.

A patient is admitted with a possible 2nd cervical vertebra injury. The nurse prepares for which most likely method to manage the patient's respiratory system? 1. Incentive spirometer every hour while awake. 2. Quad coughing 3. Humidified oxygen via face mask 4. Intubation and mechanical ventilation

Correct Answer: 4 Rationale 1: Incentive spirometer is not the most likely method of managing this patient's respiratory system. Rationale 2: Quad coughing is not the most likely method for managing this patient's respiratory system. Rationale 3: Humidified oxygen via face mask will not be sufficient to manage this patient's respiratory system. Rationale 4: Patients with 1st or 2nd cervical injuries will require mechanical ventilation because of loss of phrenic nerve enervation to the diaphragm.

An elderly patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of decreased responsiveness. The nurse realizes that which situation is the most likely cause of this change in mentation? 1. The patient's intravenous line is infiltrated. 2. The patient has been NPO for an extended period of time. 3. The patient's oxygen saturation has dropped from 96% to 90%. 4. The patient was started on a PCA pump with morphine.

Correct Answer: 4 Rationale 1: Infiltration of an intravenous line would not be a likely cause of change in mentation. Rationale 2: NPO status, as long as the patient is receiving fluids and nutrition parenterally, is not a likely etiology for this change in mentation. Rationale 3: This amount of change in oxygen saturation is not the likely cause of the patient's mental status change since the level is still within normal limits. Rationale 4: Medications are seen as the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium. This is what the nurse should suspect as the cause of the patient's new onset of decreasing responsiveness.

A patient diagnosed with a traumatic brain injury is receiving mannitol. The nurse would evaluate which findings as indicating this therapy is having its desired effects? 1. ICP is increasing 2. Serum sodium is 148 mEq/L 3. Serum osmolality is 300 mOsm 4. Osmotic gap is 12

Correct Answer: 4 Rationale 1: Mannitol is given to decrease ICP. Rationale 2: The desired response is serum sodium above 160 mEq/L. Rationale 3: The desired effect is serum osmolality greater than 320 mOsm. Rationale 4: The desired effect is an osmotic gap greater than 10.

From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated? 1. Use the prn order for morphine to control the patient's pain. 2. Use wrist restraints to maintain monitoring devices and lines. 3. Restrict visitors to times when the patient's mentation is clearest. 4. Reorient the patient to the environment as needed.

Correct Answer: 4 Rationale 1: Morphine has been linked to an increase in delirium and should be avoided if it is suspected as being the cause for the patient's delirium. Rationale 2: Delirium can be worsened by the use of physical restraints. Rationale 3: The presence of family and significant others often helps to reassure and reorient the patient. Visitation should be encouraged even during times of decreased mentation. Rationale 4: One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner.

A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective? 1. Potassium level has decreased. 2. Blood pressure has decreased. 3. Serum sodium level is increased. 4. Urine output has decreased.

Correct Answer: 4 Rationale 1: Potassium level assessment is not an essential indicator of success in the treatment of a patient with diabetes insipidus. Rationale 2: The large amount of fluid lost in diabetes insipidus causes hypotension. Continued decrease in blood pressure does not indicate that treatment is successful. Rationale 3: Continued elevation of serum sodium level would indicate that treatment is not effective. Rationale 4: Treatment for diabetes insipidus includes replacing intravascular volume and providing synthetic antidiuretic hormone. Evidence that a patient is improving would include a decrease in urine output with an increase in specific gravity.

The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide? 1. Symptoms of the concussion will continue for most of the patient's life. 2. The concussion might be healed; however, the patient will not recover from the symptoms. 3. Symptoms of the concussion will come and go depending upon the patient's health status. 4. Symptoms of a concussion can last 3 months or more.

Correct Answer: 4 Rationale 1: Symptoms of the concussion will not continue for most of the patient's life. Rationale 2: The patient will recover from the symptoms. Rationale 3: The symptoms of the concussion will not come and go depending upon the patient's health status. Rationale 4: Since almost half of patients with concussion develop postconcussive syndromes that include symptoms similar to those on presentation to the emergency department; these symptoms may continue for 3 months or more after injury.

A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension. Which finding would the nurse evaluate as indicating the therapy has had its desired effect? 1. Normal temperature 2. Systolic blood pressure of 85 mm Hg 3. Systolic blood pressure of 120 mm Hg 4. Mean arterial pressure of 88 Hg

Correct Answer: 4 Rationale 1: Temperature is not a good way to assess for therapeutic effect in this intervention. Rationale 2: Rationale 3: Systolic pressure of 120 mm Hg may be difficult to obtain without administering so much fluid that the patient develops pulmonary edema. Rationale 4: Judicious use of intravenous fluids is required when treating hypotension because too much fluid can precipitate pulmonary edema. However, medications might be needed to maintain adequate cardiac output and tissue perfusion. Current guidelines recommend that the mean arterial pressure be maintained 85 to 90 mm Hg for the first 7 days post-spinal cord injury.

A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery? 1. Right vertebral 2. Left posterior communicating 3. Left middle cerebral 4. Right middle cerebral

Correct Answer: 4 Rationale 1: The right vertebral area is not the most common site of damage causing a stroke. Rationale 2: The posterior communicating arteries are part of the circle of Willis, but are not the most common areas involved in stroke. Rationale 3: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the left side of the brain controls the right side of the body. Rationale 4: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the right side of the brain controls the left side of the body.

The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture? 1. Altered sympathetic responses 2. Alteration in pain responses 3. Alteration in position sense 4. Altered parasympathetic responses

Correct Answer: 4 Rationale 1: The sympathetic nervous system is located in the gray matter of the first thoracic through the second lumbar section of the cord. The patient does not have an injury to this region. Rationale 2: Alteration in pain responses would be seen with damage to the spinothalamic tracts. Rationale 3: Alteration in position sense would be seen with damage to the posterior column tracts. Rationale 4: The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. The patient with a fractured sacrum could experience alterations in the parasympathetic responses.

A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority? 1. Encourage the patient to drink at least 240 mL of fluids. 2. Contact the prescriber about an increase in the haloperidol dosage. 3. Place the patient on seizure precautions. 4. Hold the haloperidol dose and collaborate with the prescriber.

Correct Answer: 4 Rationale 1: There is no indication that fluid intake will treat this drug reaction. Rationale 2: The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated. Rationale 3: Seizure is a possibility, but is not the primary nursing action. Rationale 4: One nursing indication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug.

A patient with a head injury is being monitored with an intraventricular catheter. The nurse would design interventions based upon which priority nursing diagnosis (NDX)? 1. Risk for Injury 2. Decreased Intracranial Adaptive Capacity 3. Altered Comfort, Acute Pain 4. Risk for Infection

Correct Answer: 4 Rationale 1: This patient is at risk for injury, but this is not the priority NDX. Rationale 2: This patient likely has at risk for decreased intracranial adaptive capacity but this is not the priority NDX. Rationale 3: This patient may have altered comfort due to injury, procedures, or positioning, but this is not the priority NDX. Rationale 4: The placement of an intraventricular catheter to monitor intracranial pressure places the patient at risk for infection. The nurse must practice meticulous infection control measures while caring for these patients.

A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position? 1. The brain will compress the cerebral veins less in this position. 2. The ventricles of the brain will drain better in this position. 3. This position allows for less pain for the patient. 4. The cerebral spinal veins are valveless and drain by gravity.

Correct Answer: 4 Rationale 1: This statement is not physiologically correct. Rationale 2: This statement is not physiologically correct. Rationale 3: There is no reason that pain would be reduced in this position. Rationale 4: The cerebral spinal veins drain best via gravity, an important characteristic to remember when caring for patients with the risk for increased intracranial pressure as would be present in intracranial surgeries.

The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon? 1. Urine output has dropped from 100 mL each hour to 60 mL per hour. 2. The patient's hand grasps are weak bilaterally. 3. Fine crackles can be auscultated in the lung bases bilaterally. 4. The pupil on the side of the injury has become fixed and dilated.

Correct Answer: 4 Rationale 1: Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered. Rationale 2: Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness. Rationale 3: Fine crackles auscultated bilaterally in lung bases can be due several conditions, such as immobility, and is not indicative of an emergent neurological condition. Rationale 4: Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation.

A patient, admitted with syncope, is diagnosed with an 80% stenosis of the left carotid artery. In addition to assessing the patient's speech, the nurse should focus the assessment on the presence or development of which other findings? 1. Vertigo and cranial nerve palsies 2. Monocular blindness and left-sided sensory loss 3. Double vision and ataxia 4. Right sided hemineglect, sensory and motor loss

Correct Answer: 4 Rationale 1: Vertigo and cranial nerve palsies are seen with an altered vertebrobasilar circulation. Rationale 2: The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke, so left-sided sensory or motor loss will not be seen. Rationale 3: Double vision and ataxia are seen with an altered vertebrobasilar circulation. Rationale 4: The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke.

The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery. Which nursing diagnosis is the priority for care in the acute phase of this disease process? 1. Altered Nutrition: Less than Body Requirements 2. Total Self-Care Deficit 3. Decreased Intracranial Aadaptive Capacity 4. Altered Cerebral Tissue Perfusion

Correct Answer: 4 Rationale 1: While alteration of nutrition may occur, it is not the priority in the initial treatment of this condition. Rationale 2: The patient may experience self-care deficits, but this is not the priority for the initial treatment of this condition. Rationale 3: In this type of stroke, increased intracranial pressure is generally not a major concern; therefore, decreased intracranial adaptive capacity is not the priority. Rationale 4: The priority for care in the early and acute phase of a thrombotic stroke is to maintain the effect perfusion to the area near the infarct, the penumbra.

A patient is recovering from surgery to clip an aneurysm. The nurse would anticipate managing which interventions to help prevent cerebral vasospasm? 1. Infusion of packed red blood cells 2. Diuretic therapy 3. Oral fluid restriction 4. Intravenous fluid augmentation

Correct Answer: 4 Rationale 1: While support of volume is important in these patients, nothing in the scenario indicates need for packed red blood cells in this particular situation. Rationale 2: Diuretic therapy is not indicated as it may result in hypovolemia, which is contraindicated. Rationale 3: Oral fluid restriction will not support the desired effect of hypervolemia and hemodilution that is indicated for this patient. Rationale 4: Postoperative complications associated with the clipping of an aneurysm include cerebral vasospasm. Vasospasm decreases perfusion to brain tissue and is prevented and treated with "triple H therapy": hypervolemia, hypertension, and hemodilution. This combination of therapies is used to augment cerebral perfusion pressure by raising systolic blood pressure, cardiac output, and intravascular volume to increase cerebral blood flow and minimize cerebral ischemia.

An initiative for early identification of critical illness myopathy has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients? Standard Text: Select all that apply. 1. Patients with history of type 1 diabetes mellitus 2. Patients with documented presence of renal calculi 3. Patients admitted with the diagnosis of chronic bronchitis 4. Patents sedated with neuromuscular blocking agents 5. Patients who have received high dose corticosteroid therapy

Correct Answer: 4,5 Rationale 1: Elevated glucose levels have been associated with critical illness polyneuropathy. Rationale 2: Renal calculi are not associated with critical illness myelopathy. Rationale 3: Chronic bronchitis is not associated with the development of critical illness myopathy. Rationale 4: Critical illness myelopathy is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. It has been associated with neuromuscular blocking agent use. Rationale 5: Critical illness myopathy is associated with use of high dose corticosteroid therapy.

What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Assess motor and sensory function every shift. 2. Have the patient hold onto the halo struts during turns and repositioning. 3. Keep the pins and traction bars slightly loose to prevent pressure ulcers. 4. Tape a halo vest wrench to the front of the vest. 5. Use a moist cloth to clean the skin under the vest.

Correct Answer: 4,5 Rationale 1: Motor function and sensation should be assessed every 2 to 4 hours. Rationale 2: Pulling on the struts can disrupt the device integrity and possible result in spinal cord damage. Having the patient hold onto the struts would likely cause stress to the device. Rationale 3: The pins and traction bars should be firmly attached to provide stabilization. Rationale 4: A halo vest wrench is to be taped to the front of the vest to be able to remove the vest in the event the patient needs to receive cardiopulmonary resuscitation. Rationale 5: The vest is not removed for bathing, so a moist cloth is used to clean the skin under the vest.