Quiz 7 Shock and Neurologic Critical Condition

A client is admitted post traumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma scale should the nurse document?

3

The nurse is preparing to transfer Ms. D to the intensive care unit (ICU). Using SBAR (situation, background, assessment, recommendation) format, in what order will the nurse communicate pertinent information about Ms. D to the ICU nurse? 1. "Current blood pressure is 92/42, pulse rate 112, and respirations 32. Capillary blood glucose is 167 mg/dL, and lactate level is 36.04. Blood and urine culture pending" 2. "The patient has diabetes and chronic atrial fibrillation. She has been experiencing nausea, abdominal pain, and back pain. Today she was noted to be increasingly lethargic" 3. "Ms. D will need a central line insertion for fluid and vasopressor management, along with titration of norepinephrine and normal saline to maintain mean arterial pressure at 65 mm Hg" 4. "Ms. D is ready to transfer to intensive care. She has septic shock and is receiving mechanical ventilation, norepinephrine drip, and normal saline infusion through a peripheral line"

4, 2, 1, 3

When the nurse is preparing to assist with endotracheal intubation of Ms. D, in which order will these actions be accomplished? 1. Use capnography to check for exhaled carbon dioxide 2. Secure the endotracheal tube in place 3. Preoxygenate with bag-valve mask device at 100% oxygen 4. Inflate the endotracheal tube cuff 5. Obtain all needed equipment and supplies 6. Insert the endotracheal tube orally through the vocal cords

5, 3, 6, 4, 1, 2

The nursing student has just studied about carotid artery angioplasty with stenting. Which statement by the student indicates an understanding of the purpose of the procedure? A. "The stent opens the blockage enough to establish blood flow" B. "The stent occludes the abnormal artery to prevent bleeding" C. "The stent bypass the blockage for collateral circulation" D. "The stent catches any debris, particularly embolic clots"

A. "The stent opens the blockage enough to establish blood flow"

A patient has sustained a major head injury and the nurse is assessing the patient's neurologic status every 2 hours. What early sign of increased intracranial pressure does the nurse monitor for? A. Change in level of consciousness B. Cheyne-Stokes respirations C. Cushing's triad D. Dilated and nonreactive pupils

A. Change in level of consciousness

The cardiac monitor shows this rhythm (Afib). Routine treatment orders for dysthymia are in the emergency department protocols. Which action should the nurse take next? A. Continue to monitor cardiac rhythm B. Administer metoprolol 5 mg IV push C. Prepare to perform cardioversion at 50 J D. Administer amiodarone 150 mg IV push

A. Continue to monitor cardiac rhythm

The nurse is caring for a patient at risk for increased intracranial pressure (ICP). Which sign is most likely to be the first indication of increased ICP? A. Decline of level of consciousness B. Increase in systolic blood pressure C. Change in pupil size and response D. Abnormal posturing of extremities

A. Decline of level of consciousness

The nurse is caring for a patient with sepsis. What is a late clinical manifestation of shock? A. Decrease in blood pressure B. MAP is decreased by less than 10 mm Hg C. Tachycardia with a bounding pulse D. Increased urine output

A. Decrease in blood pressure

Which laboratory value indicates that beginning of severe sepsis even before other symptoms are evident? A. Decreased level of activated protein C B. Decreased serum potassium level C. Increased hemoglobin level D. Increased aPTT level

A. Decreased level of activated protein C

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestation of excessive levels of antidiuretic hormone (ADH) should the nurse assess? A. Decreased urine output B. Decreased urine specific gravity C. Increased serum sodium D. Increased blood urea nitrogen

A. Decreased urine output

A patient who had a craniotomy develops the postoperative complication of syndrome of inappropriate antidiuretic hormone. The patient's sodium level is 117 mEq/L, and the serum osmolarity is decreased. In light of this development, which intervention would the nurse question? A. Encourage oral fluids B. Slow IV infusion of hypertonic sodium C. Strict intake and output D. Daily weights

A. Encourage oral fluids

The nurse is caring for a patient receiving medication therapy to prevent recurrence of stroke. Which medication is pharmacologically appropriate for this purpose? A. Enteric-coated aspirin B. Gabapentin C. Alteplase D. Acetaminophen

A. Enteric-coated aspirin

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student nurse requires that the nurse intervene most rapidly? A. Entering the room without putting on a protective mask and gown B. Instructing the family that visits are restricted to 10 minutes C. Giving the client a warm blanket when he says he feels cold D. Checking the client's pupil response to light every 30 minutes

A. Entering the room without putting on a protective mask and gown

Which statement about assessment of skin during shock is accurate? A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes B. For all patients in shock, the skin is expected to feel warm and dry to the touch C. For a lighter skinned patient, skin is usually a whitish blue color D. For a patient with dark skin, color will be bluish gray

A. For a patient with dark skin, pallor or cyanosis is best assessed in the oral mucous membranes

The oncoming intensive care nurse is told that the patient with a traumatic brain injury manifested Cushing's Triad several minutes ago, just before shift change. Which intervention does the oncoming nurse anticipate? A. Helping family to prepare for imminent death B. Assisting with arrangements for hospice care C. Aggressive administration for hospice diuretics D. Emergency transfer to the operating room

A. Helping family to prepare for imminent death

The nurse is caring for an intubated patient with increased intracranial pressure (ICP). If the patient needs to be suctioned, which nursing action does the nurse take to avoid further aggravating the increased ICP? A. Manually hyperventilate with 100% oxygen before passing the catheter B. Maintain strict sterile technique when performing endotracheal suctioning C. Perform oral suctioning frequently, but do not perform endotracheal suctioning D. Obtain an order for an arterial blood gas before suctioning the patient

A. Manually hyperventilate with 100% oxygen before passing the catheter

The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations are markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? A. Monitor the client for signs of brain injury B. Check for hemorrhaging from the oral and nasal cavities C. Elevate the foot of the bed if the client develops symptoms of shock D. Observe for clinical indicators of decreased intracranial pressure and temperature

A. Monitor the client for signs of brain injury

A patient has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasospasm? A. Nimodipine B. Phenytoin C. Dexamethasone D. Clopidogrel

A. Nimodipine

Assessment findings of a patient with trauma injuries reveal cool and pale skin, reported thirst, urine output 100mL/8 hr, blood pressure 122/78 mm Hg, pulse 102 beats/min, and respirations 24/min with decreased breath sounds. The nurse recognizes that the patient is in which phase of shock? A. Nonprogressive B. Progressive C. Refractory D. Multiple organ dysfunction

A. Nonprogressive

Which change in the skin is an early indication of hypovolemic shock? A. Pallor or cyanosis in the mucous membranes B. Color changes in the trunk area C. Axilla and groin feel moist or clammy D. Generalized mottling of skin

A. Pallor or cyanosis in the mucous membranes

Which medical-surgical concept has the highest priority when a patient develops shock? A. Perfusion B. Fluid and electrolyte balance C. Tissue integrity D. Cellular regulation

A. Perfusion

A patient with a right cerebral hemisphere stroke may have safety issues related to which factor? A. Poor impulse control B. Alexia and agraphia C. Loss of language and analytical skills D. Slow and cautious behavior

A. Poor impulse control

What factor increases an older adult's risk for distributive (septic) shock? A. Reduced skin integrity B. Diuretic therapy C. Cardiomyopathy D. Musculoskeletal weakness

A. Reduced skin integrity

The unlicensed assistive personnel (UAP) working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instructions must the nurse give the UAP? A. Report any increase in heart rate because it is an early sign of shock B. Report any increased systolic pressure, which is an early sign of shock C. Report any changes in body temperature, which may indicate sepsis D. Report any increase in respiratory rate because of acid-base changes

A. Report any increase in heart rate because it is an early sign of shock

A patient received alteplase for the treatment of ischemic stroke. Following drug administration, the nurse monitors for which adverse effect? A. Severe headache and hypertension B. Hypotension secondary to anaphylaxis C. Respiratory depression and low O2 saturation D. Elevated hematocrit or hemoglobin

A. Severe headache and hypertension

When assessing the norepinephrine infusion site, the nurse notes that the skin around the IV insertion site is cool and pale. Which action should be taken first? A. Shut off the infusion pump B. Assess for pain at the site C. Notify the HCP about the possible norepinephrine extravasation D. Inject the pale area with phentolamine solution per hospital protocol

A. Shut off the infusion pump

When caring for a client who has sustained a head injury, it is important that the nurse assess for which clinical indicator? A. Slowing of the heart rate B. Decreased carotid pulses C. Bleeding from the oral cavity D. Absence of deep tendon reflexes

A. Slowing of the heart rate

The nurse caring for a patient who has decreased level of consciousness with the medical diagnosis of epidural hematoma. During the shift, the patient becomes lucid and is alert and talking. The family reports that this is her baseline mental status. What is the nurse's next action? A. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient B. Document the patient's exact behaviors, compare to previous nursing entries, and continue the neurologic assessments every 2 hours C. Point out to the family that the dangerous period has passed, but encourage them to leave so the patient does not become overly fatigued D. Monitor the patient for the next 48 hours to 2 weeks because a subacute condition may be slowly developing

A. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient

Which patient handling situation has the greatest potential to lead to a subdural hematoma? A. Sudden vertical elevation of head of the bed of an older person B. Log-rolling a patient who has a possible cervical spine injury C. Pulling on the affected flaccid arm of an older stroke patient D. Keeping patient flat and alternating side-lying position every 2 hours

A. Sudden vertical elevation of head of the bed of an older person

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? A. The client no longer recognizes family members B. The blood glucose level is 234 mg/dL C. The client reports a continuing headache D. The daily weight has increased 2.2 lb

A. The client no longer recognizes family members

A patient sustained a stroke that affected the right hemisphere of the brain. The patient has visual spatial deficits of proprioception. After assessing the safety of the patient's home, the home health nurse identifies which enviornmental feature that represents a potential safety problem for this patient? A. The handrail that borders the bathtub is on the right-hand side B. The patient's favorite chair faces the front door of the house C. The patient's bedside table is on the left-hand side of the bed D. Family has relocated the patient to a ground-floor bedroom

A. The handrail that borders the bathtub is on the right-hand side

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? A. Third B. Fourth C. Second D. Seventh

A. Third

At the end of the shift, the supervisor consults with the nurse about which of these oncoming staff members should be assigned to care for Ms. D. Which RN will be best to assign to care for this patient? A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months B. Newly graduated RN who has worked in the ICU as a nursing assistant and has finished the precepted orientation C. Experienced ICU RN who has been called in on a day pff to work for the first 4 hours of the shift D. RN who has been floated from the postanesthesia care unit (PACU) to the ICU for the shift

A. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months

The nurse is caring for a patient who had a craniotomy. What interventions should the nurse use to prevent respiratory complications of atelectasis and pneumonia? A. Turn frequently and encourage frequent deep breaths B. Perform deep suction frequently to keep airway patent C. Place in a high Fowler's position and apply oxygen D. Coach to perform deep coughing to expectorate secretions

A. Turn frequently and encourage frequent deep breaths

The home health nurse reads in the patient's chart that he has a mild hemiparesis and ataxia that are residual from a stroke that occurred several years ago. Based on this information, the nurse would assess for functionality and availability of what type of adaptive equipment for this patient? A. Walker and wheelchair for mobility and handrails in the bathroom B. Picture boards, flash cards, or other methods of communication C. Cell phone, computer with internet access, or medical alert device D. Hearing aid, corrective eyeglasses, dentures, and orthotic devices

A. Walker and wheelchair for mobility and handrails in the bathroom

The nurse is preparing for a teaching session for a patient at risk for septic shock. Which topic does the nurse include in this teaching? SATA A. Wash hands frequently using antimicrobial soap B. Avoid aspirin and aspirin-containing products C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher F. Take temperature once a week

A. Wash hands frequently using antimicrobial soap C. Avoid large crowds or gatherings where people might be ill D. Do not share eating utensils E. Wash toothbrushes in a dishwasher

Following a stroke, a patient demonstrates emotional lability. What is the family most likely to report? A. "He is so depressed all of the time that he hardly even eats anything" B. "He will laugh loudly and then suddenly start crying for no apparent reason" C. He seems really cheerful, almost giddy and euphoric most of the time" D. "He is starting to behave and interact with us like he did before the stroke"

B. "He will laugh loudly and then suddenly start crying for no apparent reason"

The nurse is performing a psychosocial assessment on a patient who is at risk for shock. Which statement made by the patient is of greatest concern to the nurse? A. "Do you have any idea when I might go home? No one is feeding my cat." B. "Something feels wrong, but I'm not sure what is causing me to feel this way." C. "I live alone in my house and my family lives in a different state." D. "I would usually go golfing with my friends today. I hope they are not worried about me'

B. "Something feels wrong, but I'm not sure what is causing me to feel this way."

The preferred administration time for intravenous (systemic) fibrinolytic therapy is generally within what time frame of stroke symptom onset? A. 30-60 minutes B. 3-4.5 hours C. 6-8 hours D. 24-30 hours

B. 3-4.5 hours

A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume

B. A failure of the circulatory pump

The nurse is caring for a postoperative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? A. Pulse pressure of 40 mm Hg B. A rapid, weak, thready pulse C. Warm, flushed skin D. Increased urinary output

B. A rapid, weak, thready pulse

The nurse is caring for a patient with septic shock. Which therapy specific to the management of septic shock for this patient does the nurse anticipate will be used? A. Inotropics B. Antibiotics C. Colloids D. Antidysrhythmics

B. Antibiotics

The nurse observes that a patient who had surgery for a benign hemangioblastoma has bilateral periorbital edema and ecchymosis. Because this patient's care is based on the general principles of caring for the patient with a craniotomy, what is the nurse's first action? A. Immediately inform the surgeon B. Apply cold compresses C. Check the pupillary response D. Perform a full neurologic assessment

B. Apply cold compresses

The nurse is caring for a patient who had a craniotomy. Which intervention targets the primary concern of postoperative care in the first 4-6 hours after this procedure? A. Monitoring for periorbital edema and ecchymosis around the eyes B. Assessing neurologic and vital signs every 15-30 minutes C. Monitoring complete blood count, electrolyte levels, and osmolarity D. Orienting the patient to person, place, and time

B. Assessing neurologic and vital signs every 15-30 minutes

A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli? A. Sinus bradycardia B. Atrial fibrillation C. Sinus tachycardia D. First-degree heart block

B. Atrial fibrillation

The nurse is caring for a patient who sustained a traumatic brain injury and is intubated. To prevent increased intracranial pressure, what would the nurse use to quickly detect hypercarbia? A. Pulse oximeter B. Capnography C. Arterial blood gas D. Glasgow Coma Scale

B. Capnography

The patient with a traumatic brain injury is receiving mechanical ventilation. Why does the health care provider order ventilator settings to maintain a partial pressure of arterial carbon dioxide (PaCO2) at 35-38 mm Hg? A. Lower levels of arterial carbon dioxide are essential for gas exchange B. Carbon dioxide is a vasodilator that can cause increased intracranial pressure C. Carbon dioxide is a waste product that must be eliminated from the body D. Lower levels of arterial carbon dioxide facilitate brain oxygenation

B. Carbon dioxide is a vasodilator that can cause increased intracranial pressure

The nurse is assessing a patient who was brought to the emergency department for altered mental status. In the absence of family members or witnesses to give a history, what does the nurse do to identify two conditions that could mimic emergent neurologic conditions? A. Check skin turgor and perform a bladder scan B. Check blood glucose and oxygen saturation C. Observe for jugular vein distention and pitting edema D. Observe for jaundice and abdominal distention

B. Check blood glucose and oxygen saturation

What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema? A. Improved renal blood flow B. Decreased intracranial pressure C. Maintenance of circulatory volume D. Prevention of the development of thrombi

B. Decreased intracranial pressure

A patient is showing early clinical manifestations of hypovolemic shock. The healthcare provider orders an arterial blood gas (ABG). Which ABG values does the nurse expect to see in hypovolemic shock? A. Increased pH with decreased PaO2 and increased PaCO2 B. Decreased pH with decreased PaO2 and increased PaCO2 C. Normal pH with decreased PaO2 and normal PaCO2 D. Normal pH with decreased PaO2 and decreased PaCO2

B. Decreased pH with decreased PaO2 and increased PaCO2

A patient who had a stroke several years ago continues to have the potential for aspiration. Which intervention is best to delegate to the unlicensed assistive personnel? A. Monitor the patient for and notify the charge nurse of any occurrence of coughing, choking, or difficulty breathing B. Elevate the head of the bed and slowly feed small spoonfuls of pudding, pausing between each spoonful C. Check for swallow reflex by placing index finger and thumb on the Adam's apple and palpating during swallowing D. Give the patient a glass of water before feeding solid foods, and have oral suction ready at bedside

B. Elevate the head of the bed and slowly feed small spoonfuls of pudding, pausing between each spoonful

Based on analysis of ABG values (PaCO2 62 mm Hg, PaO2 50 mm Hg, HCO3 22 mEq/L, O2 82%, pH 2.3), which collaborative intervention will the nurse anticipate next? A. Sodium bicarbonate bolus IV B. Endotracheal intubation and mechanical ventilation C. Continuous monitoring of Ms. D's respiratory status D. Nebulized albuterol therapy

B. Endotracheal intubation and mechanical ventilation

A patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question? A. Establish a large-bore peripheral IV and give crystalloid bolus B. Give furosemide (Lasix) 20 mg slow IVP C. Insert a Foley catheter and monitor intake and output D. Give high-flow oxygen via mask at 10 L/min

B. Give furosemide (Lasix) 20 mg slow IVP

In planning care for a patient with increased intracranial pressure (ICP), what does the nurse do to minimize ICP? A. Gives the bath, changes the linens, does passive range of motion (ROM) to hands/fingers, and then allows the patient to rest B. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises to hands/fingers C. Gives the bath; defers the linen change and passive ROM exercises until the danger of increased ICP has passed D. Contacts healthcare provider for specific orders about activities related to patient care that might cause increased ICP

B. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises to hands/fingers

Which laboratory value requires the most immediate action by the nurse? A. Creatinine level B. Glucose level C. Potassium level D. Hemoglobin level

B. Glucose level

While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client's color is pale and the pulse is rapid. What should the nurse conclude about the client's condition? A. Hyperventilating B. Going into shock C. Experiencing anxiety D. Developing an infection

B. Going into shock

A patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which laboratory values does the nurse seek out that are considered "hallmarks" of sepsis? A. Increased white blood cell count and increased glucose level B. Increased serum lactate level and rising band neutrophils C. Increased oxygen saturation and decreased clotting times D. Decreased white blood count with increased hematocrit

B. Increased serum lactate level and rising band neutrophils

The clinical manifestations in the first phase of sepsis-induced distributive shock result from the body's reaction to which factor? A. Leukocytes B. Infectious microorganisms C. Hemorrhage D. Hypovolemia

B. Infectious microorganisms

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6 orally. Which prescribed intervention should be implemented first? A. Administer codeine 15 mg orally for the client's headache B. Infuse ceftriaxone 2000 mg IV to treat the infection C. Give acetaminophen 650 mg orally to reduce the fever D. Give furosemide 40 mg IV to decrease intracranial pressure

B. Infuse ceftriaxone 2000 mg IV to treat the infection

In which position should the nurse initially place a client who has experienced a brain attack? A. Prone B. Lateral C. Supine D. Trendelenburg

B. Lateral

Several clients are admitted to the emergency department with brain injuries as a result of an automobile collision. The nurse concludes that the client with an injury to which part of the brain will most likely not survive? A. Pons B. Medulla C. Midbrain D. Thalamus

B. Medulla

The healthcare provider orders therapeutic hypothermia for a patient with a traumatic brain injury. What is the priority assessment during the rewarming process? A. Assess for change of mental status B. Monitor for cardiac dysrhythmias C. Watch for rebound elevation of temperature D. Observe for hypovolemic shock

B. Monitor for cardiac dysrhythmias

Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? A. Nasal cannula B. Nonrebreather C. Venturi mask D. Simple face mask

B. Nonrebreather

A stroke patient is at risk for increased intracranial pressure and is receiving oxygen 2 L via nasal cannula. The nurse is reviewing arterial blood gas (ABG) results. Which ABG value is of greatest concern for this patient? A. pH 7.32 B. PaCO2 of 60 mm Hg C. PaO2 of 95 mm Hg D. HCO3 of 28 mEq/L

B. PaCO2 of 60 mm Hg

The nurse is caring for a patient who had a stroke in the right cerebral hemisphere, and the patient demonstrates unilateral body neglect syndrome. Based on this information, which behavior would the nurse expect to observe? A. Patient uses a pencil and fingers to eat food from the meal tray B. Patient combs hair on the unaffected side but not on the affected side C. Patient tells the nurse that bathing and hygiene should be done next month D. Patient generally looks disheveled and disorganized but is always pleasant

B. Patient combs hair on the unaffected side but not on the affected side

The home health nurse is assessing a patient who had a stroke that affected the right hemisphere. What would the nurse expect to observe? A. Patient is overly anxious and cautious when asked to do a new task B. Patient is euphoric and smiling but disoriented to person, place, and time C. Patient is depressed and expresses ongoing worries about the future D. Patient has a flat affect but is able to answer most questions appropriately

B. Patient is euphoric and smiling but disoriented to person, place, and time

The nurse is caring for a patient with an ischemic stroke. Which concept underlies the rationale for placing the patient in a supine position with a low head-of-bed elevation? A. Comfort B. Perfusion C. Gas exchange D. Mobility

B. Perfusion

A patient has sustained a traumatic brain injury. Which nursing intervention is best for this patient? A. Assess vital signs every 8 hours B. Position to avoid extreme flexion of neck C. Increase fluid intake for the first 48 hours D. Restrict visitors until cognition improves

B. Position to avoid extreme flexion of neck

A postoperative hospitalized patient has a decrease in mean arterial pressure (MAP) of greater than 20 mm Hg from baseline values; elevated, thready pulse; decreased blood pressure; shallow respirations of 26/min; pale skin; moderate acidosis; and moderate hyperkalemia. The nurse recognizes that this patient is in what phase of shock? A. Compensatory/nonprogressive B. Progressive C. Refractory D. Multiple organ dysfunction

B. Progressive

A young trauma patient is at risk for hypovolemic shock related to occult hemorrhage. What baseline indicator allows the nurse to recognize the early signs of shock? A. Urine output B. Pulse rate C. Fluid intake D. Skin color

B. Pulse rate

Based on the initial history and assessment, which action prescribed by the healthcare provider (HCP) will the nurse implement first? A. Insert a foley catheter and monitor urine output hourly B. Start oxygen and maintain oxygen saturation at 90% or higher C. Place the patient on a cardiac monitor D. Check the blood glucose level

B. Start oxygen and maintain oxygen saturation at 90% or higher

A patient has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable for this patient? A. Play music for the patient for at least 30 minutes each day B. Teach the patient to test the water temperature used for bathing C. Position the patient reclining in bed or in a chair for meals D. Show a picture of the spouse and ask patient to identify the person

B. Teach the patient to test the water temperature used for bathing

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was a 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? A. The client's condition is improving B. The client's condition is deteriorating C. The client will need intubation and mechanical ventilation D. The client's medication regime will need adjustments

B. The client's condition is deteriorating

The nurse notices that a patient seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? A. Limit the diet to clear liquids given through a straw B. Withhold food and fluids until swallowing is assessed C. Monitor the patient's weight and compare trends to baseline D. Observe the patient while eating and note problematic foods

B. Withhold food and fluids until swallowing is assessed

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? A. "Your wife was not admitted within the time frame that alteplase is usually given" B. "This drug is used primarily for clients who experience an acute heart attack" C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain" D. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase"

C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain"

The emergency department (ED) nurse is giving discharge instructions to the mother of a child who bumped his head on a table. Which statement by the mother indicates an understanding of the instructions? A. "I should not let him fall asleep today or during the early evening" B. "There's really nothing to worry about. It was just a bump on the head" C. "I should take him back to the ED for weakness or slurred speech" D. "He can run and play as he usually does, as long as he doesn't climb"

C. "I should take him back to the ED for weakness or slurred speech"

The nurse is teaching a patient who will receive a disc-shaped wafer (carmustine) as part of the treatment for a brain tumor. Which statement by the patient indicates understanding of how the wafer works? A. "I'll place the wafer under my tongue and allow it to dissolve" B. "The wafer will be taped to my chest, and the drug will be absorbed" C. "The wafer will be placed directly into the cavity during the surgery" D. "The wafer is to be dissolved in water and taken with meals"

C. "The wafer will be placed directly into the cavity during the surgery"

The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling, "Ruby! Ruby!" What is the best question for the nurse to ask the patient's friends? A. "Where and why did the accident occur?" B. "How can we notify the family for consent for treatment?" C. "Was the patient using drugs or alcohol prior to the accident?" D. "Who is Ruby, and why is the patient calling for her?"

C. "Was the patient using drugs or alcohol prior to the accident?"

The nurse is conducting a presentation to a group of students on the prevention of head injuries. Which statement by a student indicates a need for additional teaching? A. "Drinking, driving, and speeding contribute to the risk for injury" B. "Males are more likely to sustain head injury compared to females" C. "Young people are less likely to get injured because of faster reflexes" D. "Following game rules and not goofing around can prevent injuries"

C. "Young people are less likely to get injured because of faster reflexes"

A patient comes to the emergency department (ED) with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? A. Whole blood B. 0.5% dextrose in water C. 0.9% sodium chloride D. Plasma protein fractions

C. 0.9% sodium chloride

The ICU nurse is caring for a patient with septic shock. Which IV infusion orders for the patient does the nurse question? A. Antibiotics B. Insulin C. 10% dextrose in water D. Synthetic activated C protein

C. 10% dextrose in water

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? A. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose B. A 42-year-old admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm C. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due D. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy

C. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due

A patient has a cardiac dysrhythmia and pulmonary problems as a result of receiving the first dose of a new IV antibiotic. The nurse recognizes that this represents what type of shock? A. Hypovolemic B. Cardiogenic C. Anaphylactic D. Septic

C. Anaphylactic

The unlicensed assistive personnel (UAP) reports repeatedly and unsuccessfully trying to take a patient's blood pressure with the electronic and manual devices. The nurse notes that the patient's apical pulse is elevated and the patient is at risk for hypovolemic shock. What is the best method for the nurse to determine the systolic blood pressure? A. Apply the electronic device to a lower extremity B. Instruct the UAP to immediately get the Doppler C. Apply the manual cuff and palpate for the systolic D. Tell the UAP to try the electronic device on the other arm

C. Apply the manual cuff and palpate for the systolic

A patient in hypovolemic shock is receiving sodium nitroprusside to enhance myocardial perfusion. What is an important nursing assessment when administering this drug? A. Assess the patient for headache because it is an early symptom of drug excess B. Assess blood pressure at least every 15 minutes because hypertension is a symptom of overdose C. Assess blood pressure at least every 15 minutes because systemic vasodilation can cause hypotension D. Assess the patient every 30 minutes for extravasation because nitroprusside can cause severe vasoconstriction and tissue ischemia

C. Assess blood pressure at least every 15 minutes because systemic vasodilation can cause hypotension

The nurse is working on a medical-surgical unit, and unlicensed assistive personnel tells the nurse that a patient who was dressing to go home suddenly developed slurred speech and left-sided weakness. What does the nurse do first? A. Instruct the patient to wait and initiate neuro checks every 2 hours B. Call the healthcare provider to obtain a delay in the discharge order C. Assess the patient within 10 minutes for signs/symptoms of a stroke D. Instruct the patient to follow up tomorrow with his primary care provider

C. Assess the patient within 10 minutes for signs/symptoms of a stroke

A patient at risk for hypovolemic shock has a central venous pressure (CVP) catheter in place. Which finding is a priority concern for the nurse? A. Heart rate is decreased from 120 to 110 per minute B. Central venous pressure is increased from 1 to 6 mm Hg C. Central venous pressure is decreased from 6 to 1 mm Hg D. Heart rate is increased from 100 to 110 per minute

C. Central venous pressure is decreased from 6 to 1 mm Hg

The patient reports a sudden, severe headache, with nausea and vomiting. He says, "This is the worst headache of my life." What condition does the nurse suspect? B. Migraine headache C. Cerebral aneurysm D. Ischemic stroke

C. Cerebral aneurysm

A patient is diagnosed with an ischemic stroke. Unlicensed assistive personnel (UAP) reports that the patient's blood pressure (BP) is 150/100 mm Hg. The patient's BP prior to the stroke was normally around 120/80 mm Hg. What action does the nurse take first? A. Immediately report BP to the healthcare provider because there is a danger of rebleeding B. Ask the UAP to repeat the BP measurement in the other extremity with a manual cuff C. Check the health care provider's orders to see if BP is within acceptable parameters D. Document BP and continue to monitor because an elevated BP is necessary for cerebral perfusion

C. Check the health care provider's orders to see if BP is within acceptable parameters

The patient at risk for hypovolemic shock tells the nurse that he is very thirsty. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) first? A. Give the patient a cup of ice water B. Assist the patient to the bathroom C. Check the patient's vital signs D. Ask the patient if he would like some juice

C. Check the patient's vital signs

A patient receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess for while administering this drug? A. Decreased urine output and decreased blood pressure B. Increased respiratory rate and increased urine output C. Chest pain and hypertension D. Bradycardia and headache

C. Chest pain and hypertension

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action? A. Perform a complete neurologic assessment B. Assess the cranial nerve functions C. Contact the Rapid Response Team D. Reassess the client in 30 minutes

C. Contact the Rapid Response Team

A patient is admitted for a closed head injury sustained during a fall down the stairs. The patient has no history of respiratory disease and no apparent respiratory distress. However, the healthcare provider orders oxygen 2 L via nasal cannula. What is the nurse's best action? A. Use pulse oximeter and apply the oxygen if the saturation levels drop below 90% B. Question the order because oxygen is unnecessary and therefore an extra cost to the patient C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure D. Apply nasal cannula as ordered and wean from oxygen when patient is discharged

C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure

Which patient is demonstrating an early indicator of change in level of consciousness? A. Middle-aged patient with a brain tumor wanders naked in the halls B. Older patient who had a stroke several days ago is snoring loudly C. Elderly patient is restless and irritable after a fall and bump to the head D. Adolescent patient is difficult to arouse, after drinking and fighting

C. Elderly patient is restless and irritable after a fall and bump to the head

The nurse is caring for a patient with right cerebral hemisphere damage. The patient demonstrates disorientation to time and place and neglect of the left visual field, and he has poor depth perception. Which task is best delegated to the unlicensed assistive personnel? A. Move the patient's bed so that his affected side faces the door B. Teach the patient to wash both sides of his face C. Ensure a safe environment by removing clutter D. Suggest to the family that they bring familiar family photos

C. Ensure a safe environment by removing clutter

The nurse is caring for a patient at risk for increased intracranial pressure related to ischemic stroke. For what purpose does the nurse place the patient's head in a midline neutral position? A. Provide comfort for the patient B. Protect the cervical spine C. Facilitate venous drainage from brain D. Maintain presence of cerebrospinal fluid

C. Facilitate venous drainage from brain

The nurse is reviewing the laboratory results of a patient with a systemic infection. What is the significance of a "left shift" in the differential leukocyte count? A. Expected finding because the patient has a serious infection B. Indication that the infection is progressing toward resolution C. Indication that the infection is outpacing the white cell production D. Important to watch for trends but otherwise not urgently significant

C. Indication that the infection is outpacing the white cell production

When the nurse is infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid fluid infusion? A. Palpating for any peripheral edema B. Monitoring urinary output C. Listening to lung sounds D. Checking for jugular venous distention

C. Listening to lung sounds

The nurse is caring for a patient at risk for septic shock from a wound infection. To prevent systemic inflammatory response syndrome, the nurse's priority is to monitor which factor? A. Patient's pulse rate and quality B. Patient's electrolyte imbalance C. Localized infected area D. Patient's intake and output

C. Localized infected area

Which information about Ms. D is most important for the nurse to communicate to the healthcare provider? A. Decreased blood pressure B. Ongoing atrial fibrillation C. Low central venous pressure D. Continued temperature elevation

C. Low central venous pressure

Which determination must be made first in assessing a patient with traumatic brain injury? A. Presence of spinal injury B. Hypovolemia with hypotension C. Patency of airway D. Glascow Coma Score

C. Patency of airway

Which patient is at risk for obstructive shock? A. Patient with a history of angina B. Patient with chronic atrial fibrillation C. Patient with pulmonary embolism D. Patient with a history of heart failure

C. Patient with pulmonary embolism

What is the priority concept for the interdisciplinary care and treatment of a patient who is suspected of having a stroke? A. Pain B. Cognition C. Perfusion D. Sensory perception

C. Perfusion

A patient is at risk for shock has had some small, subtle changes in behavior within the past hour. How does the nurse evaluate the patient's mental status throughout the night? A. Assess the patient while he or she is awake and then allow him or her to sleep until the morning B. Ask the patient and family to describe the patient's normal sleep and behavior patterns C. Periodically attempt to awaken the patient and document how easily he or she is aroused D. Allow the patient to sleep but assess respiratory effort and skin temperature

C. Periodically attempt to awaken the patient and document how easily he or she is aroused

The nurse is assessing a patient who was struck in the head several times with a baseball bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take first? A. Ask the patient to gently blow the nose; observe the nasal drainage for blood clots B. Immediately report the finding to the health care provider and document the observation C. Place a drop of the fluid on a white absorbent background and look for a yellow halo D. Assist patient to wipe his nose, but no other action is needed; he has probably been crying

C. Place a drop of the fluid on a white absorbent background and look for a yellow halo

The nurse is caring for a patient at risk for sepsis. Why does the nurse closely monitor the patient for early signs of shock? A. The patient is unable to self-identify or report these early signs B. Distributive shock usually begins as a bacterial or fungal infection C. Prevention of septic shock is easier to achieve in the early phase D. There is widespread vasodilation and pooling of blood in some tissues

C. Prevention of septic shock is easier to achieve in the early phase

The nurse is caring for an older adult patient at risk for shock. What is an early sign of shock in this patient? A. Cool, clammy skin B. Decreased urinary output C. Restlessness D. Hypotension

C. Restlessness

A patient is admitted to the critical care unit after a craniotomy to debulk a grade 3 astrocytoma. What is the priority patient problem? A. Risk for infection leading to septic shock B. Risk for memory loss and confusion C. Risk for increased intracranial pressure D. Risk for multi-organ failure

C. Risk for increased intracranial pressure

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? A. Tonic-clonic seizures B. Decerebrate posturing C. Sudden severe headache D. Narrowed pulse pressure

C. Sudden severe headache

Which condition results in blood vessels that are normally partially constricted? A. Hypoxia B. Vasodilation C. Sympathetic tone D. Decreased mean arterial pressure

C. Sympathetic tone

Which clinical finding could help the health care team differentiate a transient ischemic attack from a stroke? A. Patient has a unilateral facial droop B. Patient has slurred speech C. Symptoms resolve in 30-60 minutes D. Electrocardiogram is normal

C. Symptoms resolve in 30-60 minutes

A patient with blunt trauma to the abdomen has been NPO for several hours in preparation for a procedure and now reports thirst. What is the nurse's priority action? A. Get the patient a few ice chips or a moistened swab B. Obtain an order for a stat hematocrit and hemoglobin C. Take the patient's vital signs and compare to baseline D. Obtain an order to increase the IV rate

C. Take the patient's vital signs and compare to baseline

The nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. What is the nurse's best interpretation of this finding? A. The patient is developing type 2 diabetes B. The patient is developing type 1 diabetes C. This finding is associated with a poor outcome D. This finding is unexpected in septic shock

C. This finding is associated with a poor outcome

The nurse is assessing a patient who sustained a relatively minor head injury after a bump in the head. The nurse has greatest concern about which symptom? A. Headache B. Nausea and vomiting C. Unequal pupils D. Dizziness

C. Unequal pupils

A client with a brain attack is comatose on admission. Which clinical indicator is the nurse most likely to identify? A. Twitching motions B. Purposeful motions C. Urinary incontinence D. Unresponsiveness to pain

C. Urinary incontinence

The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hyperdynamic state. Several hours later, the patient has a rapid respiratory rate, decreased urine output, and altered level of consciousness. How does the nurse interpret this change? A. A positive response and a signal of recovery B. Temporary situation that is likely to normalize C. Worsening of the condition rather than improvement D. Expected response to standard therapies

C. Worsening of the condition rather than improvement

The student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervene when the student nurse asks the patient which question? A. "What is today's date?" B. "Who is the president of this country?" C. "Where are we right now?" D. "Is your name Mr. John Smith?"

D. "Is your name Mr. John Smith?"

The neurologist tells the nurse that the stroke patient has some deficits associated with cranial nerves V, VII, IX, X, and XII. Which intervention is the nurse most likely to initiate? A. Prevention of valsalva maneuver B. Fall precautions C. Prevention of corneal abrasions D. Aspiration precautions

D. Aspiration precautions

A patient with increased intracranial pressure is to receive IV mannitol. Which assessment would the nurse perform to prevent complications in a body system other than the nervous system? A. Assess for cardiac dysrhythmias B. Assess for gastric bleeding C. Assess for respiratory distress D. Assess for acute renal failure

D. Assess for acute renal failure

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons? A. Absent reflexes B. Flaccid muscles C. Trousseau sign D. Babinski response

D. Babinski response

What should the nurse assess for in the immediate postoperative period after a client has brain surgery? A. Tachycardia B. Constricted pupils C. Elevated diastolic pressure D. Decreased level of consciousness

D. Decreased level of consciousness

The ICU nurse observes petechiae ecchymoses, and blood oozing from the gums and other mucous membranes. How does the nurse interpret this finding? A. Pulmonary emboli (PE) B. Acute respiratory distress syndrome (ARDS) C. Systemic inflammatory response syndrome (SIRS) D. Disseminated intravascular coagulation (DIC)

D. Disseminated intravascular coagulation (DIC)

A patient had an infratentorial craniotomy. Which position does the nurse use for this patient? A. High Fowler's position, turned to the operative side B. Head of bed at 30 degrees, turned to the non-operative side C. Flat in bed, except elevate head of bed for meals and medication D. Flat and positioned side-lying, alternating sides every 2 hours

D. Flat and positioned side-lying, alternating sides every 2 hours

Which Glasgow Coma Scale (GCS) data set indicates the most severe injury for a patient with traumatic brain injury and loss of consciousness? A. GCS of 13 with loss of consciousness for 5 minutes B. GCS of 9 with loss of consciousness for 30 minutes C. GCS of 12 with loss of consciousness for 15 minutes D. GCS of 8 with loss of consciousness for 60 minutes

D. GCS of 8 with loss of consciousness for 60 minutes

Which of these actions prescribed by the HCP will be most important for the nurse to question? A. Increase oxygen flow rate B. Raise normal saline rate to 450 mL/hr C. Administer acetaminophen 650 mg rectally D. Increase norepinephrine infusion rate to 12 mcg/kg

D. Increase norepinephrine infusion rate to 12 mcg/kg

A patient is at risk for sepsis. Which assessment finding is most indicative of the hyperdynamic activity that occurs in septic shock? A. Crackles in lung bases B. Weak, rapid peripheral pulses C. Cool, clammy, cyanotic skin D. Increased pulse rate with warm, pink skin

D. Increased pulse rate with warm, pink skin

The nurse is evaluating the care and treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment? A. Blood pH of 7.28 B. Arterial PO2 of 65 mm Hg C. Distended neck veins D. Increased urinary output

D. Increased urinary output

The nurse is caring for a patient at risk for hypovolemic shock. What is the first sign of hypovolemic shock the nurse should monitor? A. Elevated body temperature B. Decreasing urine output C. Vasodilation D. Increasing heart rate

D. Increasing heart rate

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? A. Thready, weak pulse B. Narrowing pulse pressure C. Regular, shallow breathing D. Lowered level of consciousness

D. Lowered level of consciousness

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? A. Determine the level at which the client has intact sensation B. Assess the level at which the client has retained mobility C. Check blood pressure and pulse for signs of spinal shock D. Monitor respiratory effort and oxygen saturation level

D. Monitor respiratory effort and oxygen saturation level

A patient with head trauma was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock? A. Obstructive B. Cardiogenic C. Chemical-induced distributive D. Neural-induced distributive

D. Neural-induced distributive

The nurse is assessing a patient who had a traumatic brain injury and observes that the patient's right pupil appears more ovoid in shape compared to the left and to previous assessments. What is the clinical significance of this observation? A. Ovoid pupil is not significant unless the nurse observes severe hypertension, change of mental status, or respiratory depression B. Ovoid pupil is assumed to signal brain herniation in progress with a poor prognosis until proven otherwise C. Ovoid pupil is considered a normal variation for a small percentage of patients who sustain minor head injuries D. Ovoid pupil is regarded as midstage between a normal pupil and a dilated pupil and should be reported immediately

D. Ovoid pupil is regarded as midstage between a normal pupil and a dilated pupil and should be reported immediately

Which IV therapy results is the greatest increase in oxygen-carrying capacity for a patient with hypovolemic shock? A. Lactated Ringer's solution B. Hetastarch C. Fresh frozen plasma (FFP) D. Packed red blood cells

D. Packed red blood cells

The nurse hears in report that the patient with a stroke had a score of 25 on the National Institutes of Health Stroke Scale when assessed in the emergency department. After therapy and treatment, the most recent score is 20. How does the nurse interpret this information? A. Patient's condition can only be interpreted by trending several scores B. Patient should be carefully monitored for life-threatening symptoms C. Patient is possibly a little worse, but change is insignificant D. Patient is showing improvement and has fewer neurologic deficits

D. Patient is showing improvement and has fewer neurologic deficits

The nurse is performing a morning shift assessment on several patients. For which patient is the nurse immediately concerned about decreased tissue perfusion if the capillary refill time was delayed? A. Patient with diabetes mellitus B. Anemic patient C. Patient with peripheral vascular disease D. Patient with severe dehydration

D. Patient with severe dehydration

What is the best practice for managing increased intracranial pressure in a patient who experienced a stroke? A. Restrict visitors until level of consciousness improves B. Keep the environment cheerful and stimulating C. Obtain an order for a low-fat and low-sodium diet D. Position head of the bed to less than 25 degrees

D. Position head of the bed to less than 25 degrees

The stroke patient is prescribed a stool softener every morning. What is the purpose of this drug specific to this patient? A. Stimulates peristaltic action to aid defecation B. Increases frequency of bowel movements C. Decreases fluid and fiber content of stool D. Prevents Valsalva maneuver during defecation

D. Prevents Valsalva maneuver during defecation

A patient has a localized infection. What assessment findings are considered evidence of a beneficial inflammatory response? A. Decreased urine output that normalizes after fluid bolus B. Pulse rate of 120 beats/min related to increased metabolic activity C. Decreased oxygen saturation that responds to supplemental O2 D. Redness and edema that subsides in several days

D. Redness and edema that subsides in several days

A patient had a brain tumor removed. Which position does the nurse place the patient in? A. Place on operative side to protect the unaffected side of the brain B. Place flat and repositioned on either side to decrease tension on the incision C. Do not reposition unless specific positions are ordered by the surgeon D. Reposition every 2 hours but do not turn the patient onto the operative side

D. Reposition every 2 hours but do not turn the patient onto the operative side

A 70-year-old man is admitted to the hospital with an infected finger for several days' duration. He is lethargic and confused and has a temperature of 101.3. Other assessment findings include blood pressure of 94/50 mm Hg, pulse 105 beats/min, respirations of 40/min, and shallow breathing. These assessment findings indicate which type of shock? A. Hypovolemic B. Cardiogenic C. Anaphylactic D. Septic

D. Septic

The nurse is providing postoperative care for a patient who had a craniotomy. The nurse would immediately notify the surgeon of which assessment finding? A. Drainage via Jackson-Pratt of 45 mL/8 hours B. Intracranial pressure of 15 mm Hg C. PCO2 level of 35 mm Hg D. Serum sodium of 119 mEq/L

D. Serum sodium of 119 mEq/L

An LPN/LVN under the RNs supervision, is assigned to provide nursing care for a client with Guillain-Barre syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? A. Reports numbness and tingling B. Facial weakness and difficulty speaking C. Rapid heart rate of 102 beats/min D. Shallow respirations and decreased breath sounds

D. Shallow respirations and decreased breath sounds

Which statement about the systematic effects of shock is correct? A. The liver is essentially unaffected, but liver enzymes may be lower than normal B. The current heart rate and blood pressure indicate the cardiac system is at baseline C. The brain and neurologic system can withstand 10-15 minutes of severe hypoperfusion D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage

D. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage

A patient presents to the advanced stroke center with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? A. Age less than 80 years B. History of stroke C. Recent surgery D. Time of onset of symptoms

D. Time of onset of symptoms

Following a left cerebral hemisphere stroke, the patient has expressive (Broca's) aphasia. Which intervention is best to use when communicating with this patient? A. Repeat the names of objects on a routine basis B. Face the patient and speak slowly and clearly C. Obtain a whiteboard with an erasable marker D. Use a picture board that displays objects and activities

D. Use a picture board that displays objects and activities