Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
55. The nurse, caring for a patient who sustained a traumatic injury several days ago, notes that the patient is hypotensive, oliguric, and has cool, pale skin and acidosis. The nurse understands that these are manifestations of which type of shock? 1. hypovolemic. 2. cardiogenic. 3. septic. 4. anaphylactic
1. Hypovolemic. Hypovolemic shock is caused by a decrease in intravascular volume. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular fills drops. As a result, stroke volume, cardiac output, and BP decreases. Hypovolemic shock affects all body systems. Cardiogenic shock occurs when the heart's pumping ability is compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion. Patients at risk for developing infections leading to septic shock include those that are hospitalized, have debilitating chronic illness, and have poor nutritional status. Septic shock does not usually present in a patient with a traumatic injury. Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.
52. A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which findings indicates this medication has been effective? 1. increased heart rate. 2. reduced heart rate. 3. decreased respiratory rate. 4. decreased blood pressure
1. Increased heart rate. Dobutamine is a medication that mimics the fight-or-flight response of the SNS. The physiologic effect is improved perfusion and oxygenation of the heart, with increased stroke volume and heart rate, and increased cardiac output. Increased cardiac output, in turn, increases tissue perfusion and oxygenation. This medication will not reduce the heart rate, respiratory rate, or blood pressure.
54. The nurse is providing medications to increase a patient's systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion? 1. Mean arterial pressure reaches 60. 2. Mean arterial pressure reaches 90. 3. Blood pressure reaches 120/80 mmHg. 4. Urine output is 10 mL per hour
1. MAP reaches 60. A MAP of 60 is required to maintain adequate perfusion to the brain, heart, and kidneys. A MAP of 90 is considered within normal limits. A BP of 120/80 is considered normal. A urine output of 10 mL per hour would not be adequate renal perfusion.
62. A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient? 1. stop the transfusion and notify the physician. 2. compare the blood slip with the unit of blood. 3. assess vital signs and associated manifestation. 4. save the blood bag and tubing for laboratory analysis. 5. collect urine and venous blood samples according to policy
1. Stop the transfusion and notify the physician. 3. Assess vital signs and associated manifestation. 2. Compare the blood slip with the unit of blood. 4. Save the blood bag and tubing for lab analysis. 5. Collect urine and venous blood samples.
50. A patient admitted with multiple injuries is prescribed an intravenous colloid solution. Which solution would be appropriate for the nurse to infuse? 1. 0.9% normal saline. 2. 25% albumin. 3. dextrose 5% and 0.45% normal saline. 4. dextrose 5% and water
2. 25 % albumin. Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. Colloid solutions used to treat shock include 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran.
61. A patient in hypovolemic shock is receiving an intravenous colloid solution (plasma expander). Which assessment findings indicate to the nurse that the infusion rate should be reduced?(Select all that apply) 1. prothrombin time of 13.5 seconds. 2. jugular vein distention. 3. tenting of the skin. 4. increased central venous pressure. 5. auscultation of crackles and wheezes
2. JVD. 4. increased CVP. 5. auscultating of crackles and wheezes. JVD, increased central venous pressure, and crackles and wheezes indicate circulatory overload and pulmonary edema. The rate of infusion would be slowed and the physician notified. A PT time of 13.5 seconds is within normal range. Tenting of the skin would indicate dehydration and the need for more fluid replacement.
64. An adolescent is experiencing anaphylactic shock after being stung by a swarm of bees. Which medications should the nurse anticipate being provided to this patient? 1. diuretics. 2. antibiotics. 3. epinephrine. 4. beta2-agonist. 5. antihistamine.
3. epinephrine. 4. beta2-agonist. 5. antihistamine. Diuretics are used to increase urine output after fluid replacement has been initiated. Antibiotics are used to suppress organisms in septic shock.
57. A patient is diagnosed with a pneumothorax. The nurse realizes that unless this is treated, the patient is at risk for developing which type of shock? 1. neurogenic. 2. obstructive. 3. hypovolemic. 4. cardiogenic
2. obstructive. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. One cause of obstructive shock is impaired diastolic filling, as seen in a pneumothorax. Hypovolemic shock is seen in patients with a low circulating blood volume.
63. An older patient with an infected stage IV pressure ulcer is lethargic. What additional findings should the nurse expect to assess in this stage of septic shock? (Select all that apply). 1. warm, flushed skin. 2. urine output 10 mL/hr. 3. blood pressure 88/54 mmHg. 4. heart rate 118 beats per minute. 5. respiratory rate 28 per minute and shallow
2. urine output 10 mL/hr. 3. blood pressure 88/54 mmHg. 4. heart rate 118 beats per minute. 5. respiratory rate 28 per minute and shallow. Warm, flushed skin is a manifestations of early (warm) septic shock.
28. A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute. The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many mL per hour?
ANS: 27. In order to administer the dobutamine at the prescribed rate of 5 mcg/kg/minute from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hour.
49. The nurse determines that a patient is experiencing ongoing progression of a shock state. What finding led the nurse to come to this conclusion? 1. increased eosinophil level. 2. drop in blood urea nitrogen level. 3. decrease in serum glucose level. 4. low serum cardiac enzyme level
3. Decrease in serum glucose level. Serum electrolyte levels are assessed to monitor the severity and progression of shock. As shock progresses, serum glucose levels decrease. A drop in blood urea nitrogen levels means the kidneys are receiving adequate blood flow. An increase in eosinophils indicates an allergic response. Low serum cardiac enzymes indicate there is no myocardial damage.
53. The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. What should the nurse do when administering this medication? 1. Use within 8 hours of reconstitution. 2. Allow the patient to get out of bed only with assistance. 3. Use an infusion pump. 4. Administer with PVC tubing
3. Use in infusion pump. IV nitroglycerine must be mixed in glass bottles and infused through special, non-PVC tubing, because up to 40-80% of nitroglycerine can be absorbed by PVC bags or tubing.
60. The nurse is reviewing data for a patient experiencing shock. Based on this data, the nurse recognizes that the patient is in what stage of shock? Blood loss: 1950 ml. Percent of blood loss: 32%. HR: 136. BP: 80/65. RR: 28. Urine output: 12 ml/hr. Cap refill: greater than 5 seconds. Mental status: Confused. 1. compensatory. 2. early, reversible. 3. progressive.. 4. refactory.
3. progressive. The manifestations of progressive shock are: blood loss of 1500-2000 ml, 30-40% blood volume loss, heart rate greater than 120, BP and pulse pressure decreased, cap refill increased over normal, moderate tachypnea, urine output below normal, and mental status altered.
58. An older patient is diagnosed with E. coli in the bloodstream. If not treated, the nurse realizes this patient is at risk for developing which type of shock? 1. anaphylactic. 2. obstructive. 3. hypovolemic. 4. distributive
4. Distributive. Distributive shock includes several types of shock that result from widespread vasodilation and decreased peripheral resistance. As the blood volume does not change, relative hypovolemia results. One example of distributive shock is septic shock. Septic shock is one part of a progressive syndrome called systemic inflammatory response syndrome (SIRS) and is most often the result of gram-negative bacterial infections such as E. coli. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. Hypovolemic shock occurs with a decrease in circulating blood volume. Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction.
56. The nurse suspects that a patient diagnosed with a myocardical infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion? 1. urticaria. 2. laryngospasm. 3. warm extremities. 4. jugular vein distention
4. Jugular Vein Distention. JVD. JVD is seen in cardiogenic shock. Warm extremities are seen in early septic shock and anaphylactic shock. Laryngospasms and urticaria are seen in anaphylactic shock.
51. A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution does the nurse recognize would be best for this patient? 1. Dextrose 5% and 0.9% normal saline. 2. Dextrose 5% and 0.45% normal saline. 3. Dextrose 5% and water. 4. Ringer's lactate
4. Ringer's Lactate. Ringer's lactate and 0.9% saline are the fluids of choice in treating hypovolemic shock, especially in the emergency phase of care while blood is being typed and crossmatches. Large amounts of these solutions may be infused rapidly, increasing blood volume and tissue perfusion. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema.
59. The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient's problem of anxiety? 1. assessing bowel sounds. 2. assessing blood pressure and heart rate. 3. monitoring central venous pressure. 4. reducing stimuli and medicating for pain
4. reducing stimuli and medicating for pain. Interventions appropriate for the problem of anxiety include reducing stimuli, which is calming and facilitates rest, and medicating for pain because pain precipitates or aggravates anxiety. Assessing BP and HR would be appropriate for a problem with cardiac output. Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. Assessing bowel sounds would be appropriate for a problem with cardiac output.
An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.
74. Calculate the CPP: (CPP = Mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] - Diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74.
31. When caring for a patient in acute septic shock, what should the nurse anticipate? a- Infusing large amounts of IV fluids b- Administering osmotic and/or loop diuretics c- Administering IV diphenhydramine (Benadryl) d- Assisting with insertion of a ventricular assist device (VAD)
A- Infusing large amounts of IV fluids. Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.
29. The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air. In which order will the nurse implement the actions? A. Obtain blood and urine cultures. B. Give vancomycin (Vancocin) 1 g IV. C. Start norepinephrine (Levophed) 0.5 mcg/min. D. Infuse normal saline 2000 mL over 30 minutes. E. Titrate oxygen administration to keep O2 saturation >95%.
ANS: E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.
11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patients central venous pressure is 3 mm Hg. b. The patient is in sinus tachycardia at 120 beats/min. c. The patient is receiving low dose dopamine (Intropin). d. The patient has had no urine output since being admitted.
ANS: A Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patients low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
1. A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? a. Give PRN furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Administer hydrocortisone (Solu-Cortef) 100 mg IV. d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
ANS: A Furosemide will further lower the filling pressures and renal perfusion for a patient with septic shock. The other orders are appropriate. Pressure in the right atrium is CVP. A more vigorous heart contraction leads to a low CVP. PAWP represents the preload of the left ventricle.
19. During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities
ANS: A The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.
18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. obtain a 12-lead electrocardiogram (ECG). c. obtain the blood pressure. d. check the level of consciousness.
ANS: A The initial actions of the nurse are focused on the ABCsairway, breathing, and circulationand administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.
2. A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg. d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A The patients elevated pulmonary artery wedge pressure indicates volume excess. A saline infusion at 250 mL/hr will exacerbate the volume excess. The other actions are appropriate for the patient.
15. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.
ANS: A - Give normal saline IV at 500 mL/hr. Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.
14. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patients serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patients extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.
ANS: A - The patients serum creatinine level is elevated. The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patients diagnosis of cardiogenic shock.
27. Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? A. Use aseptic technique when caring for invasive lines or devices. B. Ambulate postoperative patients as soon as possible after surgery. C. Remove indwelling urinary catheters as soon as possible after surgery. D. Advocate for parenteral nutrition for patients who cannot take oral feedings. E. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
ANS: A, B, C, E Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.
26. A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? A. Prepare to administer atropine IV. B. Obtain baseline body temperature. C. Infuse large volumes of lactated Ringers solution. D. Provide high-flow oxygen (100%) by non-rebreather mask. E. Prepare for emergent intubation and mechanical ventilation.
ANS: A, B, D, E All of the actions are appropriate except to give large volumes of lactated Ringers solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringers solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.
24. After change-of-shift report in the progressive care unit, who should the nurse care for first? A. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases B. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics C. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute D. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg
ANS: B Antibiotics should be administered within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome (SIRS) and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.
9. Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.
ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.
22. The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? A. Start a normal saline infusion. B. Give epinephrine (Adrenalin). C. Start continuous ECG monitoring. D. Give diphenhydramine (Benadryl).
ANS: B Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.
10. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.
ANS: B Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.
7. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% human albumin b. Furosemide (Lasix) IV c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef)
ANS: B The PAWP indicates that the patients preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.
5. After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. nitroglycerine (Tridil). b. norepinephrine (Levophed). c. sodium nitroprusside (Nipride). d. methylprednisolone (Solu-Medrol).
ANS: B When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside is an arterial vasodilator and would further decrease SVR. Normal CVP is between 2-6. In septic shock, first give fluids, then vasopressors, then steroids.
17. The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute
ANS: B Because patients in the early stage of septic shock have warm and dry skin, the patients cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patients status.
8. The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain a. hypothermia blanket. b. lactated Ringers solution. c. two 14-gauge IV catheters. d. dopamine (Intropin) infusion.
ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.
23. Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? A. The patients urine output is 18 mL/hr. B. The patients heart rate is 110 beats/minute. C. The patient is complaining of chest pain. D. The patients peripheral pulses are weak.
ANS: C Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patients diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy.
3. A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles. b. Cool, clammy extremities. c. Apical heart rate 45 beats/min. d. Temperature 101.2 F (38.4 C).
ANS: C Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
4. An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? a. Increase the rate for the dopamine (Intropin) infusion. b. Decrease the rate for the nitroglycerin (Tridil) infusion. c. Increase the rate for the sodium nitroprusside (Nipride) infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.
ANS: C Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.
21. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? A. The patients heart rate is 58 beats/minute. B. The patients extremities are warm and dry. C. The patients IV infusion site is cool and pale. D. The patients urine output is 28 mL over the last hour.
ANS: C The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock & does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock & does not indicate a need for a change in therapy or immediate action.
20. A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? A. Insert two large-bore IV catheters. B. Initiate continuous electrocardiogram (ECG) monitoring. C. Provide oxygen at 100% per non-rebreather mask. D. Draw blood to type and crossmatch for transfusions.
ANS: C The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented.
25. After reviewing the information shown below for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Temp: 100 F (37.8 C). IV site: no redness or swelling. Oxygen sat: 93% on 2L via nasal cannula. Breath sounds: crackles bilaterally in lung bases. Platelet count: 50,000/uL. Petechia: noted on chest and legs. BP: 110/60. Pulse: 102/min. RR: 26/min. A. Temperature and IV site appearance B. Oxygen saturation and breath sounds C. Platelet count and presence of petechiae D. Blood pressure, pulse rate, respiratory rate.
ANS: C The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome (MODS) is developing. The other information will also be discussed with the health care provider but does not indicate that the patients condition is deteriorating or that a change in therapy is needed immediately.
12. A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure 92/40 mm Hg
ANS: C Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since nitroprusside is a vasodilator, the blood pressure may be low even if the medication is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.
6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood.
ANS: D Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.
13. Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation
ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.
16. When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
ANS: D Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
38. The nurse would recognize which clinical manifestation as suggestive of sepsis? a- Sudden diuresis unrelated to drug therapy. b- Hyperglycemia in the absence of diabetes. c-Respiratory rate of seven breaths per minute. d-Bradycardia with sudden increase in blood pressure.
B- Hyperglycemia in the absence of diabetes. Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.
41. A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? a-Obtain a 12-lead ECG and arterial blood gases. b-Rapidly administer 1000 mL normal saline solution IV. c-Administer norepinephrine (Levophed) by continuous IV infusion. d-Carefully insert a nasogastric tube and an indwelling bladder catheter.
B-Rapidly administer 1000 mL normal saline solution IV. Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.
46. A 50-year-old woman with a suspected brain tumor is scheduled for a computed tomography (CT) scan with contrast media. The nurse notifies the physician that the patient reported an allergy to shellfish. Which response by the physician should the nurse question? A. Infuse IV diphenhydramine prior to the procedure. B. Administer lorazepam (Ativan) before the procedure. C. Complete the CT scan without the use of contrast media. D. Premedicate with hydrocortisone sodium succinate (Solu-Cortef).
B. Administer lorazepam (Ativan) before the procedure. An individual with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.
Which lab is a sign of sepsis? a. Sed rate of 15. b. Lactate at 5. c. Amalyase at 100.
B. lactate at 5. A lab result greater than 4 indicated a need for fluid resuscitation.
Signs and symptoms of sepsis include all of the following except: a. confusion and disorientation. b. polyuria. c. tachycardia. d. fever.
B. polyuria.
44. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? A) Avoid elevating head of bed. B) Check temperature every 2 hours. C) Monitor breath sounds frequently. D) Assess skin for flushing and itching.
C) Monitor breath sounds frequently.
37. A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? a-Insulin infusion. b- IV administration of epinephrine. c- Aggressive IV crystalloid fluid resuscitation. d- Administration of nitrates and β-adrenergic blockers.
C- Aggressive IV crystalloid fluid resuscitation. Patients in septic shock require large amounts of crystalloid fluid replacement. Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be).
40. The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a-Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds. b-Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin. c-PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites. d-Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL.
C- PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites. Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock. Normal lactate levels are less than 1. Normal Pa02 is 80-100. MAP should be greater than 60 (70-100 is ideal).
47. The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? A. Antibiotics are not useful once an infection has progressed to sepsis. B. Weaning the patient away from the ventilator is the top priority in sepsis. C. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. D. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.
C. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Addititonal respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.
43. A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Is there any family history of heart disease?" b. "Do you take aspirin on a daily basis?" c. "Can you describe the quality of your chest pain?" d. "What time did your chest pain begin?"
Correct Answer: D - "What time did your chest pain begin?" Rationale: Fibrinolytic therapy should be started within 6 hours of the onset of the MI, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about fibrinolytic therapy.
32. A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of: a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.
Correct answer: b - septic shock. Rationale: Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation.
42. The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a-22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident. b-48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia. c-65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina. d-82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection.
D- 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection. A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.
36. What laboratory finding fits with a medical diagnosis of cardiogenic shock? a-Decreased liver enzymes. b-Increased white blood cells. c-Decreased red blood cells, hemoglobin, and hematocrit. d-Increased blood urea nitrogen (BUN) and serum creatinine levels
D- Increased blood urea nitrogen (BUN) and serum creatinine levels. The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.
35. A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a-Acute pain. b-Impaired tissue integrity. c-Decreased cardiac output. d-Ineffective tissue perfusion.
D- Ineffective tissue perfusion. The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.
39. Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? a- Cardiac index (CI) 5 L/min/m2. b-Central venous pressure 8 mm Hg. c-Mean arterial pressure (MAP) 86 mm Hg. d-Pulmonary artery pressure (PAP) 28/14 mm Hg.
D- Pulmonary artery pressure (PAP) 28/14 mm Hg. Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings are normal.
A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the patient for a CT scan. d. Obtain the Glasgow Coma Scale score.
a. Check the respiratory rate. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
33. Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply): a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarctedmyocardium. e. Trendelenburg positioning to facilitate venous return andincrease preload.
a - dobutamine to increase myocardial contractility. c - circulatory assist devices such as an intraaortic balloon pump. Rationale: Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.
A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."
a. "MS symptoms may be worse after the pregnancy." During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." b. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
a. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the MERCI procedure.
Which patient is most appropriate for the ICU charge nurse to assign to a RN who has floated form the medical unit? a. A 45-year-old receiving IV antibiotics for meningococcal meningitis. b. A 25-year-old admitted with a skull fracture and craniotomy the previous day. c. A 55-year-old who has increased ICP and is receiving hyperventilation therapy. d. A 35-year-old with ICP monitoring after a head injury last week.
a. A 45-year-old receiving IV antibiotics for meningococcal meningitis. -An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The post craniotomy, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critical ill patients.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
a. A patient with right-sided weakness who has an infusion of tPA prescribed. tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally.
a. Administer IV 5% hypertonic saline. -The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen will have minimal effect on the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan may prove some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Applying intermittent pneumatic compression stockings b. Assisting to dangle on edge of bed and assess for dizziness c. Encouraging patient to cough and deep breathe every 4 hours d. Inserting an oropharyngeal airway to prevent airway obstruction
a. Applying intermittent pneumatic compression stockings The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.
a. Ask family members about the patient's health history. When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 154/68, pulse 56, respirations 12. b. Blood pressure 134/72, pulse 90, respirations 32. c. Blood pressure 148/78, pulse 112, respirations 28. d. Blood pressure 110/70, pulse 120, respirations 30.
a. Blood pressure 154/68, pulse 56, respirations 12. -Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the ICP has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
A 68-year-male patient is brought to the ED by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Verify Glasgow Coma Scale (GCS) score. d. Palpate the head for hematoma or bony irregularities.
a. Check oxygen saturation. -Airway patency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.
A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Describe the use of botulism toxin (Botox) for headaches. d. Teach the patient about magnetic resonance imaging (MRI).
a. Discuss the need to stop taking the acetaminophen. The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.
A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.
a. Encourage family members to remain at the bedside. -Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so light should be dim.
Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Encourage the use of effective insect repellents during mosquito season. b. Remind patients that most cases of viral encephalitis can be cared for at home. c. Teach about the important of prophylactic antibiotics after exposure to encephalitis. d. Arrange for screening of school-age children for West Nile virus during the school year.
a. Encourage the use of effective insect repellents during mosquito season. -Epidemic encephalitis is usually spread by mosquitos and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an ICU during the initial stage. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall.
A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic
a. Focal. The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel sounds. d. Check pupil reaction to light.
a. Inspect the oral mucosa. Phenytoin can cause gingival hyperplasia, but does not affect bowel sounds, lung sounds, or pupil reaction to light.
After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms
a. Patient with myasthenia gravis who is reporting increased muscle weakness Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.
A patient with Parkinsons disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care (select all that apply)? a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. c. Serve high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.
a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. d. Place an armchair at the patient's bedside. Since the patient with Parkinsons has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinsons is a steadily progressive disease without acute exacerbations.
A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether is patient is developing post concussion syndrome? a. Short-term memory. b. Muscle coordination. c. Glasgow Coma Scale. d. Pupil reaction to light.
a. Short-term memory. -Decreased short-term memory is one indication of post concussion syndrome. The other data may be assessed but are not indications of post concussion syndrome.
When admitting a 42-year-old patient with a possible brain injury after a car accident to the ED, the nurse obtains the following information. Which finding is most important to report to the HCP? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mmHg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.
a. The patient takes warfarin (Coumadin) daily. -The use of anticoagulants increases the risk of intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient's blood pressure is 90/50 mm Hg. b. The patient complains about having a stiff neck. c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). d. The patient complains of an ongoing severe headache.
a. The patient's blood pressure is 90/50 mm Hg. To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible injury. b. give the scheduled divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.
a. assess the patient for a possible injury. The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the health care provider, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.
The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.
a. perform physically demanding activities early in the day. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)? a. side rails pads. b. tongue blade. c. oxygen mask. d. suction tubing. e. nasogastric tube.
a. side rails pads. c. oxygen mask. d. suction tubing. The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The beds side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.
The nurse is caring for a patient in septic shock. Which assessment finding should be reported to the HCP? a. skin cool and clammy. b. HR of 118. c. BP of 92/56. d. O2 sat of 93% of room air.
a. skin cool and clammy.
Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits? a. "Do you have difficulty in hearing?" b. "Are you experiencing visual problems" c. "Are you having any trouble with your balance?" d. "Have you developed any weakness on one side?"
b. "Are you experiencing visual problems". Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe.DIF: Cognitive Level: Apply (application) REF: 1334TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." Which response by the nurse specifically addresses the patient's concern? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."
b. "Epilepsy usually can be well controlled with medications." The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.
Which statement by a 40-year-old patient who is being discharged from the ED after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated. "b. "I am going to drive home and go to bed. "c. "I do not even remember being in an accident. "d. "I can take acetaminophen (Tylenol) for my headache."
b. "I am going to drive home and go to bed." -Following a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased ICP such as dizziness or nausea occur.
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for ICP monitoring. Which response by the nurse is best? a. "This type of monitoring system is complex and it is managed by skilled staff. "b. "The monitoring system helps show whether blood flow to the brain is adequate. "c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure. "d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."
b. "The monitoring system helps show whether blood flow to the brain is adequate." -Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members' anxiety.
A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away painful stimulus. The nurse records the patient's Glasgow Coma Scale as a. 8. b. 11. c. 13. d. 15.
b. 11. -The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
A hospitalized patient complains of a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially? a.Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (MS Contin) d. Butalbital and aspirin (Fiorinal)
b. Acetaminophen (Tylenol) The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
An unconscious 39-year-old male patient is admitted to the ED with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Refer the family members to the hospital counseling service to deal with their anxiety. d. Call the family's pastor or spiritual advisor to take them to the chapel while care is given.
b. Allow the family to stay with the patient and briefly explain all procedures to them. -The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
Which assessments should the nurse make to monitor a patient's cerebellar function? (Select all that apply.) a. Test for graphesthesia. b. Observe arm swing with gait. c. Perform the finger-to-nose test. d. Assess heat and cold sensation. e. Measure strength against resistance.
b. Observe arm swing with gait. c. Perform the finger-to-nose test. The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.
b. Assist the patient onto the bedside commode every 2 hours. Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Observe for agitation and paranoia. b. Assist with active range of motion (ROM). c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.
b. Assist with active range of motion (ROM). ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send to culture and sensitivity.
b. Check the drainage for glucose content. -Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
After endotracheal suctioning, the nurse notes that the ICP for a patient with a traumatic head injury has increased from 14 to 17 mmHg. Which action should the nurse take first? a. Document the increase in ICP. b. Ensure that the patient's neck is in neutral position. c. Notify the HCP about the change in pressure. d. Increase the rate of prescribed propofol (Diprivan) infusion.
b. Ensure that the patient's neck is in neutral position. -Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the HCP about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the ICP.
Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity. b. Flaccidity. c. Impaired sensation. d. Hyperactive reflexes.
b. Flaccidity. Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours. d. Apply cold packs intermittently to face.
b. Insert nasogastric tube to low suction. -Rhinorrhea may indicate a dural tear with CSF leakage. Insertion of a NG tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.
After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).
b. Notify the patient's health care provider. The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) a. Monitor for photophobia. b. Observe for bleeding at the puncture site. c. Keep patient NPO until gag reflex returns. d. Check pulse and blood pressure frequently. e. Assess orientation to person, place, and time.
b. Observe for bleeding at the puncture site. d. Check pulse and blood pressure frequently. e. Assess orientation to person, place, and time. Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebral angiography, the nurse should assess for bleeding at the site and bleeding that may affect pulse and blood pressure. Neuro status should be assessed often. There is no reason to keep the patient NPO. Photophobia is not expected.
Which finding for a patient who has a head injury should the nurse report immediately to the HCP? a. Intracranial pressure is 16 mmHg when patient is turned. b. Pale yellow urine output is 1200 mL over the last 2 hours. c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mmHg. d. Ventriculostomy drained 40 mL of CSF in the last 2 hours.
b. Pale yellow urine output is 1200 mL over the last 2 hours. -The high urine output indicates diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.
The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.
b. Place medications in the home medication organizer. LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.
A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the ED. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.
b. Prepare the patient for craniotomy. -The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If ICP is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.
An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.
b. Prepare the patient for lumbar puncture. After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure. Herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate.
Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? a. Specific gravity of 1.007 b. Protein of 65 mg/dL (0.65 g/L) c. Glucose of 45 mg/dL (1.7 mmol/L). d. White blood cell (WBC) count of 4 cells/L.
b. Protein of 65 mg/dL (0.65 g/L) The protein level is high. The specific gravity, WBCs, and glucose values are normal.
Which action will the ED nurse anticipate for a patient diagnoses with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the OR. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for MRI. d. Arrange to admit the patient to the neuralgic unit for 24 hours of observation.
b. Provide discharge instructions about monitoring neurologic status. -A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not usually indicated in a patient with a concussion.
A patient admitted with a diffuse axonal injury has a systemic blood pressure of 106/52 mmHg and an ICP of 14 mmHg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the HCP. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.
b. Report the BP and ICP to the HCP. -Calculate the cerebral perfusion pressure (CPP): (CPP=mean arterial pressure [MAP]-ICP). MAP=DBP + 1/3 (systolic blood pressure [SBP]-diastolic blood pressure [DBP]). Therefore the MAP is 70 and the CPP is 56 mmHg, which is below the normal of 60 to 100 mmHg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the HCP. Continued monitoring and documentation will also be done, but they are not the first action that the nurse should take.
Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Respiratory effort c. Grip strength d. Level of consciousness
b. Respiratory effort Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction? a. Pupil reaction b. Respiratory rate c. Reflex reaction time d. Level of consciousness
b. Respiratory rate. Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse and blood pressure and assess the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible but monitoring for hemorrhage after cerebral angiogram has a higher priority
A patient with possible viral meningitis is admitted to the nurse unit after lumbar puncture was performed in the ED. Which action prescribed by the HCP should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
b. Restrict oral fluids to 1000 mL daily. -The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of CSF from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the CSF analysis.
A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care? a. Prevent falls. b. Stabilize mood. c. Avoid aspiration. d. Improve memory.
b. Stabilize mood. A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg test does not assess orientation, thermoregulation, or discomfort.
A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Put a moist hot pack on the patient's neck. b. Start the prescribed PRN O2 at 6 L/min. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.
b. Start the prescribed PRN O2 at 6 L/min. Acute treatment for cluster headache is administration of 100% O2 at 6 to 8 L/min. If the patient obtains relief with the O2, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.
b. Suggest that the patient exercise regularly during the day. Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms, and RLS is likely to progress in most patients.
A patient with Parkinson's disease has bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.
b. Suggest that the patient rock from side to side to initiate leg movement. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.
Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Encourage a decreased evening intake of fluid. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.
b. Teach the patient how to use the Credé method. The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
After evacuation of an epidural hematoma, a patient's ICP is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the HCP? a. Pulse 102 beat/minute. b. Temperature 101.6 F. c. Intracranial pressure 15 mmHg. d. Mean arterial pressure 90 mmHg.
b. Temperature 101.6 F. -Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.
The nurse has administered prescribed IV mannitol (Osmitrol) in an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure. b. Oxygen saturation. c. Intracranial pressure. d. Hemoglobin and Hematocrit.
c. Intracranial pressure. -Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce Hct and increase BP, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.
The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.
b. The patient had a recent acute myocardial infarction. The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.
The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. The patient has difficulty talking. c. The blood pressure is 142/88 mm Hg. d. There are fine crackles at the lung bases.
b. The patient has difficulty talking. Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.
A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans? a. The patient is anxious about the test results. b. The patient reports a previous allergy to shellfish. c. The patient has back pain when lying flat for more than 4 hours. d. The patient drank apple juice 4 hours before the scheduled procedure.
b. The patient reports a previous allergy to shellfish. A contrast medium containing iodine is injected into the subarachnoid space during a myelogram. The patient's allergy would contraindicate the use of this medium. The health care provider may need to provide orders to treat back pain after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but procedural plans would not need to be changed.
Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass
b. Tuning fork Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination.
Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging? a. Triceps reflex response graded at 1/5 b. Unintended weight loss of 15 pounds c. Patient report of chronic difficulty in falling asleep d. 10 mm Hg orthostatic drop in systolic blood pressure
b. Unintended weight loss of 15 pounds Although changes in appetite are normal with aging, a 15-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.
Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? a. Assist to stand and ambulate. b. Withhold oral fluids and food. c. Insert an oropharyngeal airway. d. Apply artificial tears every hour.
b. Withhold oral fluids and food. The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions.
When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.
b. antiparkinsonian drugs. The clinical diagnosis of Parkinson's is made when tremor, rigidity, and akinesia, and postural instability are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided reflexes d. Difficulty in understanding commands
d. Difficulty in understanding commands Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. have the patient practice facial and tongue exercises. b. ask simple questions that the patient can answer with "yes" or "no." c. develop a list of words that the patient can read and practice reciting. d. prevent embarrassing the patient by changing the subject if the patient does not respond.
b. ask simple questions that the patient can answer with "yes" or "no." Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
b. aspirin (Ecotrin). Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
Which type of medication is administered to a patient who screened positive for sepsis? a. oral antibiotics. b. broad spectrum IV antibiotics. c. narrow spectrum IV antibiotics. d. antiviral IV.
b. broad spectrum IV antibiotics.
When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.
b. inquire about urinary tract problems. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
b. risk for injury related to denial of deficits and impulsiveness. Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that Plavix will dissolve clots in the cerebral arteries. d. that Plavix will reduce cerebral artery plaque formation.
b. to call the health care provider if stools are tarry. Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."
c. "I will lie down someplace dark and quiet when the headaches begin." It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? a. Sensation on the left side of the body b. Reasoning and problem-solving ability c. Ability to understand written and oral language d. Voluntary movements on the right side of the body
c. Ability to understand written and oral language The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.
Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Administer lorazepam (Ativan) 4 mg IV. d. Obtain computed tomography (CT) scan.
c. Administer lorazepam (Ativan) 4 mg IV. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient
c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed clopidogrel (Plavix). d. Infuse the prescribed IV metoprolol (Lopressor).
c. Administer the prescribed clopidogrel (Plavix). Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN.
45. Which interventions should be used for anaphylactic shock (select all that apply)? a. Antibiotics b. Vasodilator c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion f. Crystalloid volume expansion
c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion Due to the massive vasodilation, release of vasoactive mediators, and increased in capillary permeability from the immediate reaction, fluid leaks from the vascular space into the interstitial space. By administering a colloid (which contain larger particles that do not penetrate the semipermable membrane), the large particles will stay intravascularly. Due to their smaller size particle composition, a crystalloid would not stay intravascularly and leak interstitially.
A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.
c. Ask the patient to keep a headache diary. The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment? a. Tests for light touch before testing for pain. b. Has the patient close the eyes during testing. c. Asks the patient if the instrument feels sharp. d. Uses an irregular pattern to test for intact touch.
c. Asks the patient if the instrument feels sharp. When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the left hand. d. Teach the patient the "chin-tuck" technique.
c. Assist the patient to eat with the left hand. Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to UAP who regularly work in the ICU? a. Document ICP every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.
c. Check capillary blood glucose every 6 hours. -Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of CSF color and ICP require RN-level education and scope of practice. Although repositioning is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.
A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." Which nursing diagnosis is most appropriate for the patient? a. Situational low self-esteem related to increasing dependence on others b. Interrupted family processes related to effects of illness of a family member c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
c. Disabled family coping related to inadequate understanding by patient's spouse. The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent aches. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.
c. Explain that the aspirin is ordered to decrease stroke risk. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings? a. Cerebellar injury b. A brainstem lesion c. Frontal lobe damage d. A temporal lobe lesion
c. Frontal lobe damage. Expressive speech (ability to express the self in language) is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech.
A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives
c. How to draw up and administer injections of the medication. Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.
The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. Encourage adolescents and young adults to avoid crowds in the winter. b. Vaccinate 11- and 12-year old children against Haemophilus influenzae. c. Immunize adolescents and college freshmen against Neisseria meningitides. d. Emphasize the importance of hand washing to prevent the spread of infection.
c. Immunize adolescents and college freshmen against Neisseria meningitides. -The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but is is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Ibuprofen b. Multivitamin c. Acetaminophen d. Diphenhydramine
d. Diphenhydramine Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.
c. Keep the head of the bed elevated to 30 degrees. -The patient with increased ICP should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increase ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
48. A patient's localized infection has become systemic and septic shock is suspected. What medication is expected to treat septic shock refractory to fluids? a. Insulin infusion b. Furosemide (Lasix) IV push c. Norepinephrine administered by titration d. Administration of nitrates and β-adrenergic blockers
c. Norepinephrine administered by titration. If fluid resuscitation using crystalloids is not effective, vasopressor medications such as norepinephrine (Levophed) and dopamine are indicated to restore mean arterial pressure (MAP). Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Furosemide (Lasix) is indicated for patients with fluid volume overload. Insulin infusion may be administered to normalize blood sugar and improve overall outcomes, but it is not considered a medication used to treat shock.
Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient has minor elevations in the liver function tests. d. Patient's most recent blood pressure is 156/92 mm Hg.
c. Patient has minor elevations in the liver function tests. Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.
When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? a. Apply an eye patch to the left eye. b. Approach the patient from the left side. c. Place objects needed for activities of daily living on the patient's right side. d. Reassure the patient that the visual deficit will resolve as the stroke progresses.
c. Place objects needed for activities of daily living on the patient's right side. During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. ICP of 15 mmHg. b. CSF drainage of 25 mL/hour. c. Pressure of oxygen in brain tissue (PbtO2) is 14 mmHg. d. Cardiac monitor shows sinus tachycardia at 128 beats/minute.
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mmHg. -The PbtO2 should be 20 to 40 mmHg. Lower levels indicate brain ischemia. An ICP of 15 mmHg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
Which information about a 60-yr-old patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient walks a mile each day for exercise. b. The patient complains of pain with neck flexion. c. The patient has an increased serum creatinine level. d. The patient has the relapsing-remitting form of MS.
c. The patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is difficult to arouse. d. The BP increases to 140/62 mmHg.
c. The patient is difficult to arouse. -The change in LOC is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indictor of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient states, "My symptoms started with a terrible headache." d. The patient has a history of brief episodes of right-sided hemiplegia.
c. The patient states, "My symptoms started with a terrible headache." A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin
Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)
d. Electroencephalography (EEG) Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.
c. Time and observe and record the details of the seizure and postictal state. Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
How should the nurse assess the patient's trigeminal and facial nerve function (CNs V and VII)? a. Check for unilateral eyelid droop. b. Shine a light into the patient's pupil. c. Touch a cotton wisp strand to the cornea. d. Have the patient read a magazine or book.
c. Touch a cotton wisp strand to the cornea. The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve.
A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.
c. assist the patient into a chair. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response is a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.
c. decorticate posturing. -Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
A 40-yr-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and adult children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. prophylactic antibiotics to decrease the risk for aspiration pneumonia. c. option of genetic testing for the patient's children to determine their own HD risks. d. lifestyle changes of improved nutrition and exercise that delay disease progression.
c. option of genetic testing for the patient's children to determine their own HD risks. Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. prophylactic clipping of cerebral aneurysms. b. heparin via continuous intravenous infusion. c. oral administration of low dose aspirin therapy. d. therapy with tissue plasminogen activator (tPA).
c. oral administration of low dose aspirin therapy. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
After the ED nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient who cranial x-ray shows a linear skull fracture. b. A 30-year-old patient who has initial Glasgow Coma Scale score of 13. c. A 40-year-old patient who lost consciousness for a few seconds after a fall. d. A 50-year-old patient who right pupil is 10 mm and unresponsive to light.
d. A 50-year-old patient who right pupil is 10 mm and unresponsive to light. -The dilated and non responsive pupil may indicate an intracerebral hemorrhage and increased ICP. The other patients are not an immediate risk for complications such as herniation.
The nurse expects the assessment of a patient who is experiencing a cluster headache to include a. nuchal rigidity. b. projectile vomiting. c. unilateral ptosis. d. throbbing, bilateral facial pain.
c. unilateral ptosis. Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.
c. visual deficits. Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
34. The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are: a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.
d - level of consciousness, urine output, and skin color and temperature.
A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure? a. Enforce NPO status for 4 hours. b. Transfer the patient to radiology. c. Administer a sedative medication. d. Help the patient to a lateral position.
d. Help the patient to a lateral position. For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.
Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements
d. Imbalanced nutrition: less than body requirements The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (Chest x-ray) d. Noncontrast computed tomography (CT) scan
d. Noncontrast computed tomography (CT) scan. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway
d. Risk for aspiration related to inability to protect airway. Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
A patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.
d. Swab the nasopharyngeal mucosa for cultures. -Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotics should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.
The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the HCP? a. Complain of severe headache. b. Large contusion behind left ear. c. Bilateral periorbital eccymosis. d. Temperature of 101.4 F (38.6 C).
d. Temperature of 101.4 F (38.6 C). -Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the HCP. The other findings are typical of a patient with a basilar skull fracture.
A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
d. The patient has atrial fibrillation and takes warfarin (Coumadin). The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patient's blood pressure (BP) is usually about 180/90 mm Hg.
d. The patient's blood pressure (BP) is usually about 180/90 mm Hg. Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the HCP? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101 F (38.3 C). d. The patient's blood pressure is 88/42 mmHg.
d. The patient's blood pressure is 88/42 mmHg. -Shock is a serious complication of meningitis, and the patient's low BP indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.
62-yr-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dosage? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.
d. The patient's blood pressure is 92/52 mm Hg. Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.
When assessing a patient with a possible stroke, the nurse finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question? a. Infuse normal saline at 75 mL/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
d. Titrate labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patient's room are turned off and the blinds are shut. d. UAP enter the patient's room without a mask.
d. UAP enter the patient's room without a mask. -Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.
A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information indicates a need for change in the medication or dosage? a. Shuffling gait b. Cogwheel rigidity of limbs c. Tremor at rest d. Uncontrolled head movement
d. Uncontrolled head movement. Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.
30. A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.
d. neurogenic shock from massive vasodilation. Rationale: Neurogenic shock results in massive vasodilation without compensation as a result of the loss of sympathetic nervous system vasoconstrictor tone. Massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and, ultimately, impaired cellular metabolism. Clinical manifestations of neurogenic shock are hypotension (from the massive vasodilation) and bradycardia (from unopposed parasympathetic stimulation).
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.
d. teach the family that emotional outbursts are common after strokes. Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
Sepsis can be defined as: a. pneumonia. b. similar to the common cold. c. a bad infection. d. the body's response to an infection.
d. the body's response to an infection.
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.
d. tissue plasminogen activator (tPA) infusion. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
What is the most important assessment finding that demonstrates that anaphylactic shock treatment is effective?
oxygen saturation.
