test two practice questions
A 65 year old client is prescribed ipratropium (atrovent) for the treatment of asthma. Which of the following conditions should be reported to the HCP before giving this client the ipratropium? A) a reported allergy to peanuts B) a history of intolerance to albuterol (proventil, VoSpire) C) a history of bronchospasms D) a reported allergy to chocolate
A
A nurse walks in to a client who is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? A. Chest tube insertion on the left side. B. Chest tube insertion on the right side. C. Intubation D. Tracheostomy
A
The nurse is caring for a child who is in the hospital experiencing sickle cell crisis. The parents are asking the nurse which treatment will help cure the child. The nurse responds with which of the following? A. Treatment is aimed at pain control, oxygen therapy, and hydration, but does not provide a cure. B. Treatment with morphine will cure sickle cell disease. C. Treatment with an exchange transfusion of blood will cure the child. D. There is no treatment for sickle cell crisis.
A
The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? A) stridor B) occasional pink-tinged sputum C) respiratory rate of 24 BPM D) a few basilar lung crackles on the right
A rationales in saunders ch. 20
the nurse checks the residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount for the nurse to take? A) hold the feeding and reinstill the residual amount B) reinstill the amount and continue with administering the feeding C) elevate the clients head at least 45 degrees and administer the feeding D) discard the residual amount and proceed with administering the feeding
A rationales in saunders ch. 20
the nurse is preparing to administer medication using a clients nasogastric tube. Which actions should the nurse take before administering the medication? select all that apply. A) check residual volume B) aspirate the stomach contents C) turn off suction to the nasogastric tube D) remove the tube and place it in the other nostril E) test the stomach contents for PH indicating acidity
A,B, C, E rationales for 37 -49 in saunders ch. 20
A patient who has recovered from ARDS in the ICU is now malnourished and has lost a significant amount of weight. The physician orders TPN to add nutrition for the patient, who subsequently develops re-feeding syndrome. Which of the following signs or symptoms would the nurse expect to see with re-feeding syndrome? Select all that apply. A. Impaired mental status B. Insulin resistance C. Seizures D. Persistent weight loss E. Constipation
A,B,C
A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply A. Decreased atelectasis B. Reduced need for endotracheal intubation C. Mobilization of secretions D. Decreased fluid accumulation E. Increased response to corticosteroid therapy
A,C,D
A client is receiving treatment for asthma with albuterol (proventil, Vospire) the nurse teaches the client that while serious adverse effects are uncommon. the following may occur. (select all that apply) A) tachycardia B) sedation C) temporary dyspnea D) nervousness E) headache
A,D,E rational for questions 28-36 can be found in in Adams book chap. 39
A commonly prescribed mast cell stabilizer used for asthma is: A. Albuterol B. Budesonide C. Cromolyn sodium D. Theophylline
Answer: C. Cromolyn sodium C: Cromolyn sodium is a mast stabilizer commonly prescribed for patients with asthma.A: Albuterol is not a mast cell stabilizer; it is a short-acting beta2 adrenergic agonist.B: Budesonide is an inhaled corticosteroid.D: Theophylline is classified as methylxanthine.
Which of the following values is considered normal for ICP? 1. 0 to 15 mm Hg 2. 25 mm Hg 3. 35 to 45 mm Hg 4. 120/80 mm Hg
Answer: 1. 0 to 15 mm Hg Normal ICP is 0-15 mm Hg.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: 1. A positive Brudzinski's sign 2. A negative Kernig's sign 3. Absence of nuchal rigidity 4. A Glascow Coma Scale score of 15
Answer: 1. A positive Brudzinski's sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. Option B: Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Option C: Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Option D: A Glasgow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). 2. Emergent; the client is poorly oxygenated. 3. Normal 4. Significant; the client has alveolar hypoventilation.
Answer: 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Option B: Oxygenation is evaluated through PaO2 and oxygen saturation. Option D: Alveolar hypoventilation would be reflected in an increased PaCO2.
Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? 1. Ataxia and confusion 2. Sodium depletion 3. Tonic-clonic seizure 4. Urinary incontinence
Answer: 1. Ataxia and confusion A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Options B, C, and D: Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.
The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: 1. Desmopressin (DDAVP, Stimate) 2. Dexamethasone (Decadron) 3. Ethacrynic acid (Edecrin) 4. Mannitol (Osmitrol)
Answer: 1. Desmopressin (DDAVP, stimate) A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Option B: Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may be ordered for the head injured patient. Options C and D: Ethacrynic acid and mannitol are diuretics, which would be contraindicated.
Which neurotransmitter is responsible for may of the functions of the frontal lobe? 1. Dopamine 2. GABA 3. Histamine 4. Norepinephrine
Answer: 1. Dopamine The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it's such an important neurotransmitter in schizophrenia.
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? 1. Evaluate urine specific gravity 2. Anticipate treatment for renal failure 3. Provide emollients to the skin to prevent breakdown 4. Slow down the IV fluids and notify the physician
Answer: 1. Evaluate urine specific gravity Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. Option B: There's no evidence that the client is experiencing renal failure. Option C: Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Option D: Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? 1. Hemorrhagic skin rash 2. Edema 3. Cyanosis 4. Dyspnea on exertion
Answer: 1. Hemorrhagic skin rash DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? 1. Laceration of the middle meningeal artery 2. Rupture of the carotid artery 3. Thromboembolism from a carotid artery 4. Venous bleeding from the arachnoid space
Answer: 1. Laceration of the middle meningeal artery Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. Options B and C: An embolic stroke is a thromboembolism from a carotid artery that ruptures. Option D: Venous bleeding from the arachnoid space is usually observed with a subdural hematoma.
Which of the following assessment data indicated nuchal rigidity? 1. Positive Kernig's sign 2. Negative Brudzinski's sign 3. Positive homan's sign 4. Negative Kernig's sign
Answer: 1. Positive Kernig's sign A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition.
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Reposition the client to avoid neck flexion 2. Administer 1 g Mannitol IV as ordered 3. Increase the ventilator's respiratory rate to 20 breaths/minute 4. Administer 100 mg of pentobarbital IV as ordered.
Answer: 1. Reposition the client to avoid neck flexion The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. Options B, C, and D: If nursing measures prove ineffective notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? 1. Side-lying, with legs pulled up and head bent down onto the chest 2. Side-lying, with a pillow under the hip 3. Prone, in a slight Trendelenburg's position 4. Prone, with a pillow under the abdomen.
Answer: 1. Side-lying, with legs pulled up and head bent down onto the chest The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.
Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Slow, irregular respirations 2. Rapid, shallow respirations 3. Asymmetric chest expansion 4. Nasal flaring
Answer: 1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Options B, C, and D: Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? 1. Unequal pupil size 2. Decreasing systolic blood pressure 3. Tachycardia 4. Decreasing body temperature
Answer: 1. Unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Option B: Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. Option C: It increases the pressure on the vagus nerve, which produces bradycardia. Option D: It causes an increase in body temperature from hypothalamic damage.
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1. Urine output increases 2. Pupils are 8 mm and nonreactive 3. Systolic blood pressure remains at 150 mm Hg 4. BUN and creatinine levels return to normal
Answer: 1. Urine output increases Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Option B: Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. Options C and D: No information is given about abnormal BUN and creatinine levels or that Manitoulin is being given for renal dysfunction or blood pressure maintenance.
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1. Urine output increases 2. Pupils are 8 mm and nonreactive 3. Systolic blood pressure remains at 150 mm Hg 4. BUN and creatinine levels return to normal
Answer: 1. Urine output increases Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Option B: Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. Options C and D: No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? 1. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. 2. Administer phenytoin (Dilantin) 200 mg PO daily. 3. Teach patient about the need for good oral hygiene. 4. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
Answer: 2. Administer phenytoin (Dilantin) 200 mg PO daily. Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize. Options A, C, and D: Documentation of the seizure, patient teaching, and planning of care are complex activities that require RN level education and scope of practice.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? 1. Count the rate to be sure the ventilations are deep enough to be sufficient 2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. 3. Call the physician to adjust the ventilator settings. 4. Check deep tendon reflexes to determine the best motor response
Answer: 2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? 1. Position the client flat in bed 2. Check the fluid for dextrose with a dipstick 3. Suction the nose to maintain airway patency 4. Insert nasal and ear packing with sterile gauze
Answer: 2. Check the fluid for dextrose with a dipstick Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Option A: Placing the client flat in bed may increase ICP and promote pulmonary aspiration. Option C: The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Option D: Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.
A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose 3. Clear CSF, elevated protein, and decreased glucose 4. Clear CSF, decreased pressure, and elevated protein
Answer: 2. Cloudy CSF, elevated protein, and decreased glucose A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 1. Bloody drainage from the ears 2. Frequent swallowing 3. Guaiac-positive stools 4. Hematuria
Answer: 2. Frequent swallowing Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Option A: Blood or fluid draining from the ear may indicate a basilar skull fracture.
The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
Answer: 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1. Vomiting continues 2. Intracranial pressure (ICP) is increased 3. The client needs mechanical ventilation 4. Blood is anticipated in the cerebrospinal fluid (CSF)
Answer: 2. Intracranial pressure (ICP) is increased Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Option A: Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. Option C: An LP may be performed on clients needing mechanical ventilation. Option D: Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? 1. Limiting conversation with the child 2. Keeping extraneous noise to a minimum 3. Allowing the child to play in the bathtub 4. Performing treatments quickly
Answer: 2. Keeping extraneous noise to a minimum A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. Option A: There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. Option C: The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Option D: Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? 1. Bladder infection 2. Middle ear infection 3. Fractured clavicle 4. Septic arthritis
Answer: 2. Middle ear infection Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is frequently also found.
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. 3. Dilantin should be mixed in dextrose in water before administration. 4. Dilantin should be administered through an IV catheter in the client's hand.
Answer: 2. Rapid Dilantin administration can cause cardiac arrhythmias. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Option A: Therapeutic drug levels range from 10 to 20 mg/ml. Option C: Dilantin shouldn't be mixed in solution for administration. However, because it's compatible with normal saline solution, it can be injected through an IV line containing normal saline. Option D: When given through an IV catheter hand, Dilantin may cause purple glove syndrome.
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? 1. Abnormal flexion of the upper extremities and extension of the lower extremities 2. Rigid extension and pronation of the arms and legs 3. Rigid pronation of all extremities 4. Flaccid paralysis of all extremities
Answer: 2. Rigid extension and pronation of the arms and legs Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs.
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? 1. Complete admission assessment. 2. Set up oxygen and suction equipment. 3. Place a padded tongue blade at bedside. 4. Pad the side rails before patient arrives
Answer: 2. Set up oxygen and suction equipment. The LPN/LVN can set up the equipment for oxygen and suctioning. Focus: Delegation/supervision. Option A: The RN should perform the complete initial assessment. Option C: Tongue blades should not be at the bedside and should never be inserted into the patient's mouth after a seizure begins. Option D: Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and family.
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? 1. "Watch him for keyhole pupil the next 24 hours." 2. "Expect profuse vomiting for 24 hours after the injury." 3. "Wake him every hour and assess his orientation to person, time, and place." 4. "Notify the physician immediately if he has a headache."
Answer: 3. "Wake him every hour and assess his orientation to person, time, and place." Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are frequently assessed for 24 hours. Option A: A keyhole pupil is found after iridectomy. Option B: Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. Option D: A slight headache may last for several days after concussion; severe or worsening headaches should be reported.
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? 1. Extent of intracranial bleeding 2. Sites of brain injury 3. Activity of the brain 4. Percent of functional brain tissue
Answer: 3. Activity of the brain An EEG measures the electrical activity of the brain. Options A and B: Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. Option D: Percent of functional brain tissue would be determined by a series of tests.
When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? 1. An interval when the client's speech is garbled 2. An interval when the client is alert but can't recall recent events 3. An interval when the client is oriented but then becomes somnolent 4. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.
Answer: 3. An interval when the client is oriented but then becomes somnolent A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Option A: Garbled speech is known as dysarthria. Option B: An interval in which the client is alert but can't recall recent events is known as amnesia. Option D: Warning symptoms or auras typically occur before seizures.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. Give the client a warming blanket 2. Administer low-dose barbiturate 3. Encourage the client to hyperventilate 4. Restrict fluids
Answer: 3. Encourage the client to hyperventilate Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. Option A: A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. Option B: High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Option D: Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? 1. Subdural hematoma 2. Subarachnoid hemorrhage 3. Epidural hematoma 4. Contusion
Answer: 3. Epidural hematoma An epidural hematoma occurs when blood collects between the skull and the dura mater. Option A: In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. Option B: In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. Option D: A contusion is a bruise on the brain's surface.
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? 1. Assess full ROM to determine extent of injuries 2. Call for an immediate chest x-ray 3. Immobilize the client's head and neck 4. Open the airway with the head-tilt-chin-lift maneuver
Answer: 3. Immobilize the client's head and neck All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. Option A: ROM would be contraindicated at this time. Option B: There is no indication that the client needs a chest x-ray. Option D: In addition, the head-tilt-chin-lift maneuver wouldn't be used until the cervical spine injury is ruled out.
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? 1. Assess full ROM to determine extent of injuries 2. Call for an immediate chest x-ray 3. Immobilize the client's head and neck 4. Open the airway with the head-tilt-chin-lift maneuver
Answer: 3. Immobilize the client's head and neck All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. Option A: ROM would be contraindicated at this time. Option B: There is no indication that the client needs a chest x-ray. Option D: In addition, the head-tilt-chin-lift maneuver wouldn't be used until the cervical spine injury is ruled out. 8. Answer: 4. Tetraplegia
A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? 1. No precautions are required as long as antibiotics have been started 2. Maintain enteric precautions 3. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics 4. Maintain neutropenic precautions
Answer: 3. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.
While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? 1. Frontal 2. Occipital 3. Parietal 4. Temporal
Answer: 3. Parietal The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. Option A: The frontal lobe regulates thinking, planning, and judgment. Option B: The occipital lobe is primarily responsible for vision function. Option D: The temporal lobe regulates memory.
Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure
Answer: 3. Restlessness and confusion The earliest symptom of elevated ICP is a change in mental status. Option A and D: Bradycardia, widened pulse pressure, and bradypnea occur later. Option B: The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? 1. To reduce intraocular pressure 2. To prevent acute tubular necrosis 3. To promote osmotic diuresis to decrease ICP 4. To draw water into the vascular system to increase blood pressure
Answer: 3. To promote osmotic diuresis to decrease ICP Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.
Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet 3. Supination of arms, dorsiflexion of feet 4. Back arched; rigid extension of all four extremities.
Answer: 4. Back arched; rigid extension of all four extremities. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by the arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Option A: Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? 1. Widening pulse pressure 2. Decrease in the pulse rate 3. Dilated, fixed pupil 4. Decrease in LOC
Answer: 4. Decrease in LOC A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Options A, B, and C: Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: 1. Skull fracture 2. Concussion 3. Subdural hematoma 4. Epidural hematoma
Answer: 4. Epidural hematoma The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.
Problems with memory and learning would relate to which of the following lobes? 1. Frontal 2. Occipital 3. Parietal 4. Temporal
Answer: 4. Temporal The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. Option A: The frontal lobe primarily functions to regulate thinking, planning, and judgment. Option B: The occipital lobe functions regulate vision. Option C: The parietal lobe primarily functions with sensory function.
After a hypophysectomy, vasopressin is given IM for which of the following reasons? 1. To treat growth failure 2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3. To reduce cerebral edema and lower intracranial pressure 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
Answer: 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. After hypophysectomy or removal of the pituitary gland, the body can't synthesize ADH. Option A: Somatropin or growth hormone, not Vasopressin is used to treat growth failure. Option B: SIADH results from excessive ADH secretion. Option C: Mannitol or corticosteroids are used to decrease cerebral edema.
The most severe form of meningitis is considered to be: A. Bacterial. B. Aseptic. C. Septic. D. Viral.
Answer: A. Bacterial. Bacterial meningitis is the most severe form of meningitis.
Identify the bacteria not associated with the cause of bacterial meningitis: A. Cryptococcus neoformans. B. Haemophilus influenzae. C. Neisseria meningitidis. D. Streptococcus pneumoniae.
Answer: A. Cryptococcus neoformans. Cryptococcus neoformans is a fungi and not responsible for the development of bacterial meningitis. The rest can cause bacterial meningitis.
Which of the following is a type of embolism? A. Travelling emboli. B. Fat emboli. C. Burn emboli. D. Diabetic emboli.
Answer: B. Fat emboli. B: Fat emboli are one of the types of emboli. A: Travelling emboli is not a type of emboli. C: Burn emboli are not a type of emboli. D: Diabetic emboli are not a type of emboli.
The pressure required in the pleural space to keep the lungs inflated is: A. Positive. B. Negative. C. Atmospheric. D. All of the above.
Answer: B. Negative. B: The pressure in the pleural space is normally negative to maintain lung inflation. A: Positive pressure in the pleural space leads to pneumothorax. C: Atmospheric pressure in the pleural space leads to pneumothorax. D: Not all of the options are correct.
One of the recommended antibiotics for patients with bacterial meningitis that could cross the blood brain barrier is: A. Penicillin. B. Vancomycin. C. Ciprofloxacin. D. All of the above.
Answer: B. Vancomycin. B: Vancomycin hydrochloride could be administered intravenously to patients with bacterial meningitis. A: Penicillin is not recommended for patients with bacterial meningitis. C: Ciprofloxacin is not recommended for patients with bacterial meningitis. D: Not all of the options are correct.
Clinical manifestations related to pneumothorax include the following except for: A. Pleuritic pain. B. Respiratory distress. C. Acrocyanosis. D. Tachypnea.
Answer: C. Acrocyanosis. C: Acrocyanosis is not a sign of pneumothorax. A: Pleuritic pain is a clinical manifestation of pneumothorax. B: Respiratory distress is a clinical manifestation of pneumothorax. D: Tachypnea is a clinical manifestation of pneumothorax.
Obstruction of the airway in the patient with asthma is caused by all of the following except: A. Thick mucus B. Swelling of bronchial membranes C. Destruction of the alveolar wall D. Contraction of muscles surrounding the bronchi
Answer: C. Destruction of the alveolar wall C: There is no destruction of the alveolar wall in asthma.A: Thick mucus causes obstruction of the airway.B: Swelling of the bronchial membranes causes bronchoconstriction or obstruction of the airway.D: Contraction of muscles surrounding the bronchi is a cause of obstruction of the airway.
The following are nursing interventions to assist in the prevention of pulmonary embolism in a hospitalized patient include all except: A. A liberal fluid intake. B. Assisting the patient to do leg elevations above the level of the heart. C. Encouraging the patient to dangle his or her legs over the side of the bed for 30 minutes, four times a day. D. The use of elastic stockings, especially when decreased mobility would promote venous stasis.
Answer: C. Encouraging the patient to dangle his or her legs over the side of the bed for 30 minutes, four times a day. C: Dangling could get the emboli stuck and may impede blood flow. A: A liberal fluid intake may help dissolve the clot. B: Leg elevations are done to avoid impeding blood flow. D: Elastic stockings could prevent venous stasis.
There are several comorbid conditions that accompany asthma but it does not include: A. Gastroeasophageal reflux B. Drug-induced asthma C. Hypertension D. Allergic bronchopulmonary aspergillosis
Answer: C. Hypertension C: Hypertension is not a comorbid condition of asthma.A: GERD occurs along with asthma in some patients.B: Drug-induced asthma is a comorbid condition of asthma.D: Allergic bronchopulmonary aspergillosis is a comorbid condition of asthma.
Histamine, a mediator that supports the inflammatory process in asthma, is secreted by: A. Eosinophils B. Lymphocytes C. Mast cells D. Neutrophils
Answer: C. Mast cells C: When the mast cells are activated, it releases several chemicals called mediators, and one of them is histamine.A: Eosinophils are part of the inflammatory process in asthma.B: Lymphocytes have a role in the inflammatory process in asthma.D: Neutrophils are part of the inflammatory process in asthma
Bacterial meningitis alters intracranial physiology, causing: A. Cerebral edema. B. Increased permeability of the blood-brain barrier. C. Raised intracranial pressure. D. All of the above changes.
Answer: D. All of the above changes. D: All of the options listed above are caused by bacterial meningitis. A: Cerebral edema is caused by bacterial meningitis. B: Increased permeability of the blood brain barrier ia caused by meningitis. C: Raised intracranial pressure is caused by bacterial meningitis.
Which of the following should the nurse assess in a patient with pneumothorax? A. Tracheal alignment. B. Expansion of the chest. C. Breath sounds. D. All of the above.
Answer: D. All of the above. D: All of the options listed should be assessed by the nurse in a patient with pneumothorax. A: Tracheal alignment should be assessed in a patient with pneumothorax. B: Expansion of the chest should be assessed in a patient with pneumothorax. C: Breath sounds should be assessed in a patient with pneumothorax.
The strongest predisposing factor for asthma is: A. Chronic exposure to airway irritants B. Exercise C. Medications D. Allergy
Answer: D. Allergy D: Allergy is the strongest predisposing factor for asthma.A: One of the causes of chronic exposure to airway irritants.B: Exercise is one of the predisposing factors of asthma.C: Medications can also start the development of asthma.
What are the possible complications in a patient with pulmonary embolism? A. Right ventricular failure B. Cardiogenic shock C. Septic shock D. Both A and B.
Answer: D. Both A and B. D: Both right ventricular failure and cardiogenic shock are possible complications in a patient with pulmonary embolism. A: Right ventricular failure is a possible complication in a patient with pulmonary embolism. B: Cardiogenic shock is a possible complication in a patient with pulmonary embolism. C: Septic shock is not a complication in pulmonary embolism.
The following are types of pneumothorax except: A. Trauma. B. Simple. C. Tension. D. Direct.
Answer: D. Direct. D: There is no direct type of pneumothorax. A: Trauma pneumothorax is a type of pneumothorax. B: Simple pneumothorax is a type of pneumothorax. C: Tension pneumothorax is a type of pneumothorax.
During assessment, the nurse knows that well-recognized signs common to all types of meningitis include all of the following except? A. Positive Kernig's sign. B. Positive Brudzinski's sign. C. Photophobia. D. Negative Kernig's sign.
Answer: D. Negative Kernig's sign. A patient with meningitis exhibits a positive and not a negative Kernig's sign. Choices A, B, and C are symptoms of bacterial meningitis.
The following are diagnostic tests for a patient with pulmonary embolism except: A. Chest x-ray B. ECG C. ABG analysis D. Pulmonary function tests
Answer: D. Pulmonary function tests D: Pulmonary function tests are not performed in a patient with pulmonary embolism. A: Chest x-ray is a diagnostic test for patients with pulmonary embolism. B: ECG is a diagnostic test for patients with pulmonary embolism. C: ABG analysis is a diagnostic test for patients with pulmonary embolism
An initial characteristic symptom of a simple pneumothorax is: A. ARDS. B. Severe respiratory distress. C. Sudden onset of chest pain. D. Tachypnea and chest discomfort.
Answer: D. Tachypnea and chest discomfort. D: The patient experiences chest discomfort and tachypnea initially. A: The patient does not experience ARDS initially in a simple pneumothorax. B: The patient does not experience severe respiratory disease initially in a simple pneumothorax. C: The patient does not experience sudden onset of chest pain initially in a simple pneumothorax.
A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.
Answer: D. Take measures to prevent injury. Protecting the client from injury is the immediate priority during a seizure. Option A: Elevating the head of the bed would have no effect on the client's condition or safety. Option B: Restraining the client's arms and legs could cause injury. Option C: Placing a tongue blade or other object in the client's mouth could damage the teeth.
A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. 1. Decerebrate posturing 2. Dilated nonreactive pupils 3. Deep tendon reflexes 4. Absent corneal reflex
Answers: 2, 3, 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.
A nurse is caring for a patient who is in respiratory distress because of ARDS. Which of the following nursing diagnoses would most likely be associated with this condition? A. Disturbed personal identity B. Ineffective tissue perfusion C. Impaired urinary elimination D. Ineffective thermoregulation
B
The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? A) call the HCP B) place tube in a bottle of sterile water C) replace the chest tube system immediately D) place a sterile dressing over the disconnection site.
B rationales in saunders ch. 20
While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? A) call HCP to reinsert the tube B) grasp the retention sutures to spread the opening C) call the respiratory therapy department to reinsert the tracheotomy D) cover the tracheostomy site with sterile dressing to prevent infection
B rationales in saunders ch. 20
the nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? A) do nothing because this is an expected finding B) check for an air leak, because the bubbling should be intermittent C) increase the suction pressure so that the bubbling becomes vigorous D) clamp the chest tube and notify the HCP immediately
B rationales in saunders ch. 20
A nurse is caring for a patient with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply. A. Pulse oximetry of 94% on room air B. A PaO2 level below 60 mmHg C. An ABG pH level of 7.35 D. A pCO2 level over 50 mmHg E. A respiratory rate of over 16/minute
B, D
A 25-year-old patient in the ICU is being treated for acute respiratory distress syndrome (ARDS). The patient is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the patient to the respiratory therapist working with her? A. The patient needs a hemoglobin level drawn B. The patient needs more oxygen because of his saturations C. The patient needs endotracheal suctioning D. The patient needs an arterial blood gas drawn
D
A client who recieved a prescription for zafirlukast (accolate) returns to his providers office after three days complaining that " the drug is not working". she reports mild but continued dysnea and has had to maintain consistent use of her broncodilator inhaler, pirbuterol (maxair) what does the nurse suspect is the cause of the failure of the zafirlukast? A) the client is not taking the drug correctly. B) the client is not responding to the drug and will need to be switched to another formulation C) the drug has not had sufficient time of use to have full effects D) the pirbuterol inhaler is interacting with the zafirlukast
C
A client with asthma has a prescription for two inhalers, albuterol (proventil, Vospire) and beclomethasone (qvar). How should the nurse instruct this client on the proper use of the inhalers? A) use the albuterol inhaler, and use the beclomethasone only if symptoms are not relieved B) use the beclomethasone inhaler, and use the albuterol only if symptoms are not relieved. C) use the albuteral inhaler, Wait 5-10 minutes, then use the beclomethasone inhaler. D) use the beclomethasone inhaler, wait 5-10 minutes then use the albuteral inhaler
C
Which of the following drugs is most immediately helpful in treating a severe acute asthma attack? A) beclomethasone ( Qvar) B) Zileuton ( Zyflo CR) C) Albuterol ( Proventil, Ventolin) D) Salmeterol ( sevevent)
C
the nurse is preparing to administer medication using a clients nasogastric tube connected to suction. To administer the medication the nurse should take which action? A) position the client supine to assist in medication absorption B) aspirate the nasogastric tube after administration to maintain patency C) clamp the nasogastric tube for 30-60 minutes following administration of the medication D) change suction to low intermittent suction for 30 minutes after medication administration
C rationales in saunders ch. 20
the registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? A) mark the tube at 10 inches (25.5cm) B) mark the tube at 32 inches (81 cm) C) place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. D) place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum
C rationales in saunders ch. 20
the nurse is assessing the functioning of the chest tube drainage system in the client who just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply A) excessive bubbling in the water seal chamber B) Vigorous bubbling in the suction control chamber C) drainage system maintained below the clients chest D) 50 ml of drainage in the drainage collection chamber E) Occlusive dressing in place over the chest tube insertion site. F) fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
C,D,E,F rationales in saunders ch. 20
A 26-year-old patient is admitted to the hospital in severe respiratory distress. His oxygen saturations are 80% despite supplemental oxygen provided by facemask. The physician decides to intubate the patient to help with his breathing oxygenation. Which medication would the nurse most likely administer when assisting with intubation? A. Modafinil (Provigil) B. Phentermine (Adipex-P) C. Zolpidem (Ambien) D. Midazolam (Versed)
D
A child with suspected sickle cell disease (SCD) is in the clinic for laboratory studies. The parents ask the nurse what results will tell the physician that their child has SCD. The nurse responds that which of the following is increased in this disease? A. Hematocrit B. Hemoglobin C. Platelet count D. Reticulocyte count
D
A client has been using a fluticasone (flovent) inhaler as a component as his asthma therapy. He returns to his health care provider's office complaining of a sore mouth. On inspection, the nurse notices white patches in the clients mouth. What is a possible explanation for these findings? A) the client has been consuming hot beverages after the use of the inhaler B) the client has limited his fluid, resulting in dry mouth C) the residue of the inhaler propellant is coating the inside of the mouth D) the client has developed thrush as a result of the fluticasone
D
The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH and notes a pH of 7.35. Based on this information , which action should the nurse take at this time? A) retest pH with another strip B) document the tube is in the right place C) check the placement by auscultating for air injected into the tube D) Call the HCP for request script for chest X-ray
D rationales in saunders ch. 20
the nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? A) stay very still B) exhale very quickly C) inhale and exhale quickly D) perform the valsalva maneuver
D rationales in saunders ch. 20
the nurse is inserting a nasogastric tube in an adult client. during the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? A) insert tube quickly B) notify HCP ASAP C) remove the tube and reinsert it when the respiratory distress subsides D) pull back on the tube and wait until the respiratory distress subsides
D rationales in saunders ch. 20
The nurse assesses a patient for a possible pulmonary embolism. The nurse looks for the most frequent sign of: A. Cough B. Hemoptysis C. Syncope D. Tachypnea.
D. Tachypnea. D: Tachypnea is the most common sign to be found among patients with pulmonary embolism. A: Cough is not a sign of pulmonary embolism. B: Hemoptysis is not a sign of pulmonary embolism. C: Syncope is not a sign of pulmonary embolism.
Possible systemic reactions to inhaled Corticosteriods
Thrush if the do not rince mouth after use hyperglycemia, peptic ulcer disease, GI bleed, poor wound healing, infections and mood changes.
a 45 year old patient with chronic asthma is on beclomethasone ( flovent). What must the nurse monitor when caring for this patient?
make sure the client understands asthma and the prescribed medications. Corticosteroid inhalers do not often cause systemic effects but the client should be educated on the symptoms and how to manage them just in case.
A 72 year old male patient has recently been started on an Ipratropium ( atrovent) inhaler. What teaching is important for the nurse to provide?
the nurse must make sure the client understands the potential adverse effects related to the anticholinergic effects of this med. Patient is at a higher risk of urine retention, glaucoma, other visual distrurbances and constipation. the client must know how to monitor for these symptoms and when to call thier HCP
