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Adv. Med Surg Exam 7 (Ch 63-73)
Terms in this set (166)
The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?
1 Clear cornea
2 Constricted pupil
3 Marked blurring of vision
4 Watery ocular discharge
tonometry measures ?
the measurement of intraocular pressure
Normal IOP range
a set of charts with various geometric shapes in black and white, used for detecting defects of the central visual field.
Helps determine macular problems
The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?
1 Pupillary reacton
2 Extraocular muscle function
3 Eyelid drooping
4 Eyeball oscillation movements
When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:
1- 5 to 10 mm Hg.
2- 10 to 20 mm Hg.
3- 20 to 30 mm Hg.
4- over 30 mm Hg.
Which term refers to the absence of the natural lens?
small fragile bone making up part of the front inner walls of each eye socket and providing room for the passage of the lacrimal ducts
forms part of the posterior portion of the nose, the orbit, and the floor of the cranium
A client in the emergency room was involved in a motor vehicle accident which caused blunt facial trauma, especially to the orbit of the skull. Which bones are in danger of fracture in this type of injury? Select all that apply.
1, 2, 5
The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder?
1 Age younger than 40 years
2 Hyperopia since age 20 years
3 History of respiratory disease
4 Prolonged use of corticosteroids
clouding of the lens of the eye
impairment of vision as a result of old age
hearing impairment in old age
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?
1 Ishihara polychromatic plates
2 Visual field
3 Amsler grid
4 Slit lamp
A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?
1 BUN and creatinine
2 AST and ALT
3 Hemoglobin and hematocrit
4 Platelet count
A client is having a routine eye examination. The procedure being performed is done by using an instrument to indent or flatten the surface of the eye. This is known as ________ and it is routinely done to test for ________.
1 tonometry; intraocular pressure
2 retinoscopy; detached retina
3 tonometry; macular degeneration
4 retinoscopy; cataracts
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?
1 Ishihara polychromatic plates
2 Visual field
3 Amsler grid
4 Slit lamp
Edema of the conjunctiva is termed which of the following?
Which manifestation is the most problematic for the client diagnosed with Ménière disease?
4 Hearing loss
Which condition is characterized by the formation of abnormal spongy bone around the stapes?
2 Middle ear effusion
3 Chronic otitis media
4 Otitis externa
A nurse practitioner in an emergency room receives a telephone call from a mother whose 4-year-old child has a mosquito stuck in his external ear canal. Which of the following is the best information the nurse could give the mother?
1 Irrigate the ear canal with warm water to flush out the insect.
2 Use an aural suction cup to pull out the insect.
3 Insert a cotton-tipped applicator (e.g., Q-tip) to trap the insect and slowly pull the applicator backward.
4 Instill a few drops of warmed mineral oil to cover the insect.
The nurse is performing an assessment of a patient's ears. When looking at the tympanic membrane, the nurse observes a healthy membrane. What should the appearance be?
1 Pearly gray and translucent
2 White and cloudy
3 Pink with white exudate
4 Dark yellow with cerumen
A dietary modification for a patient with Ménière's disease would be:
1 A decrease in sodium intake to 2,000 mg daily.
2 Fluid restriction to 2 L/day.
3 An increase in calcium to 1 g/day.
4 An increase in vitamin C to 1.5 g/day.
A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do?
1 Stand at a position diagonal to the client.
2 Have the client use a finger to occlude the ear to be tested.
3 Stand about 1 to 2 feet away from the ear to be tested.
4 Speak a phrase in a low normal tone of voice.
___________ test- used to evaluate cerebellar function and balance
A patient comes to the clinic with some hearing loss. The physician is unable to observe the tympanic membrane due to the accumulation of cerumen. What intervention can the nurse provide so that observation can be made?
1 The nurse can remove the wax with a cerumen curette.
2 The ear can be irrigated with cool water until all of the wax is removed.
3 The nurse can instill a small amount of mineral oil into the canal and have the patient return for removal of the wax.
4 The nurse can instill mineral oil into the canal and immediately irrigate to remove the adherent wax.
Involuntary rapid eye movements
If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing
1 Facial nerve paralysis.
3 motor impairment.
A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate?
1 "You have some fluid that has collected in your middle ear but no infection."
2 "It has resulted from the several recurrent episodes of acute otitis media you've had."
3 "You have a common infection in one of the bones of your face."
4 "Your eardrum has ruptured because of the extreme pressure in your middle ear from the infection."
The eardrum. A structure that separates the outer ear from the middle ear and vibrates in response to sound waves.
hardening/ abnormal growth of the bony tissue of the middle ear
The _____________ is a canal that connects the middle ear to the nasopharynx, which consists of the upper throat and the back of the nasal cavity. It controls the pressure within the middle ear, making it equal with the air pressure outside the body
The eustachian tube is a canal that connects the middle ear to the nasopharynx, which consists of the upper throat and the back of the nasal cavity. It controls the pressure within the middle ear, making it equal with the air pressure outside the body
A client has been diagnosed with otosclerosis. The nurse explains to the client that this is a common cause of hearing impairment among adults and is the result of a bony overgrowth of the:
3 tympanic membrane
The nurse is caring for a client who just returned from a trip requiring an airline flight. The client commented on how his ears hurt upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?
1 Eustachian tube
3 Tympanic membrane
hearing test using a tuning fork; checks for differences in bone conduction and air conduction
The parent of a young client with severe hearing loss is quite concerned about the child's future independence because of impaired hearing. Which type of hearing loss is usually irreversible?
4 noise exposure
A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?
1 External ear
2 Middle ear
3 Inner ear
4 Tympanic membrane
Which statement describes benign paroxysmal positional vertigo (BPPV)?
1 The vertigo is usually accompanied by nausea and vomiting.
2 The onset of BPPV is gradual.
3 BPPV is caused by tympanic membrane rupture.
4 BPPV is stimulated by the use of certain medications, such as acetaminophen.
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:
1 cranial nerves I and II.
2 cranial nerves III and V.
3 cranial nerves VI and VIII.
4 cranial nerves IX and X.
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:
1 evaluation of the corneal reflex response.
2 examination of the fundus of the eye.
3 assessment of the client's gait.
4 evaluation of bowel and bladder functions.
The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?
1 The inability to tell how a mouse and a cat are alike
2 The inability to maintain steady balance for the
3 Romberg test
4 Absence of movement below the waist
The trochlear nerve controls which function?
1 Movement of the tongue
2 Hearing and equilibrium
3 Visual acuity
4 Eye muscle movement
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?
1 Withhold anticonvulsant medications for 24 to 48 hours before the exam
2 Maintain NPO status for 6 hours before the procedure 3 Sedate the client before the procedure, per orders
4 Instruct the client that a standard EEG takes 2 hours
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?
In humans there are 31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each pair connects the spinal cord with a specific region of the body. Near the spinal cord each spinal nerve branches into two roots.
The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste?
Which lobe of the brain is responsible for concentration and abstract thought?
A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected?
1 Temporal lobe
2 Inferior posterior frontal areas
3 Posterior frontal area
4 Parietal-occipital area
the inability to recognize familiar objects.
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?
1 Administer antihistamines according to the physician's prescription
2 Keep the room brightly lit and play soothing music in the background
3 Help the client take a brisk walk around the testing area
4 Encourage the client to drink liberal amounts of fluids
What part of the brain controls and coordinates muscle movement?
4 Brain stem
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.
1 Cranial nerve I
2 Cranial nerve II
3 Cranial nerve III
4 Cranial nerve IV
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
lack of muscle coordination
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
1 Capillary refill of 2 seconds
3 Cool, dry skin
4 Urine output of 100 mL/hr
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
4 - 2
LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?
1 50 to 100 mL/h
2 100 to 150 mL/h
3 150 to 200 mL/h
4 More than 200 mL/h
For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
1 Encouraging oral fluid intake
2 Suctioning the client once each shift
3 Elevating the head of the bed 90 degrees
4 Administering a stool softener as ordered
To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
2 Trigeminal neuralgia
3 Hypostatic pneumonia
4 Brain tumor
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
1 Elevate the head of the bed.
2 Complete a head-to-toe assessment.
3 Administer morning dose of anticonvulsant.
4 Administer Percocet as ordered.
The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.
Percocet is known as?
The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client?
1 Apply warm or cool cloths to the forehead or back of the neck
2 Maintain hydration by drinking eight glasses of fluid a day
3 Perform the Heimlich maneuver
4 Use pressure-relieving pads or a similar type of mattress
Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.
The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action?
1 Inspect the ICP monitor to ensure it is working properly.
2 Administer acetaminophen per orders.
3 Provide ventriculostomy care.
4 Assess for signs and symptoms of infection.
The nurse needs to control the fever by administering the ordered acetaminophen as the priority action. An increase in the client's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the client has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.
5 Pupillary constriction
1, 2, 3
At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.
Cushing's triad has three classic signs?
This is seen with pressure on the ________ as a result of brain stem herniation.
three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation
Which phase of a migraine headache usually lasts less than an hour?
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as
Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The client has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the client has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.
Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?
1 Fluid volume deficit
2 Risk for infection
3 Ineffective cerebral tissue perfusion
4 Risk for injury
The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The client is at risk for injury, fluid volume deficit due to a possible fluid restriction to maintain normovolemia, and infection due to the placement of the intraventricular catheter, but these are not the priority.
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?
1 Three hours
2 One hour
3 Two hours
4 Six hours
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
1 "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."
2 "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."
3 "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing."
4 "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
2 in 2 to 3 days
3 after 1 week
4 upon transfer to a rehabilitation unit
Which is the initial diagnostic test for a stroke?
1 Carotid Doppler
3 Transcranial Doppler studies
4 Noncontrast computed tomography
The initial diagnostic test for a stroke is nonconstrast computed tomography performed emergently to determine whether the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
1 Every 15 minutes
2 Every 30 minutes
3 Every 45 minutes
4 Every hour
Drug that immediately dissolves clots
How long of a window from the onset of the stroke do you have to give this drug?
tPA (tissue plasminogen activator)
A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain?
Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.
Which of the following is accurate regarding a hemorrhagic stroke?
1 Main presenting symptom is an "exploding headache."
2 Functional recovery usually plateaus at 6 months.
3 One of the main presenting symptoms is numbness or weakness of the face.
4 It is caused by a large-artery thrombosis.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?
1 Elevating the head of the bed to 30 degrees
2 Monitoring for seizure activity
3 Administering a stool softener
4 Maintaining a patent airway
Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
1 Transient ischemic attack (TIA)
2 Left-sided cerebrovascular accident (CVA)
3 Right-sided cerebrovascular accident (CVA)
4 Completed Stroke
When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?
1 Anticipate the client will exhibit some degree of expressive or receptive aphasia.
2 Place the wheelchair on the client's left side when transferring him into a wheelchair.
3 Provide close supervision because of the client's impulsiveness and poor judgment.
4 Support the right arm with a sling or pillow to prevent subluxation.
The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.
"Explosive headache" may indicate what type of stroke?
temporary episodes with a duration of less than 24 hours of impaired neurologic functioning caused by an inadequate flow of blood to a portion of the brain
Mini strokes usually a warning sign for a bigger stroke
Transient ischemic attack (TIA)
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?
1 Comprehend spoken words
2 Form words that are understandable
3 Form words that are understandable or comprehend spoken words
4 Speak at all
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
1 Limited attention span and forgetfulness
2 Visual agnosia
3 Lack of deep tendon reflexes
4 Auditory agnosia
Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?
1 Stent placement
2 Removal of the carotid artery
3 Percutaneous transluminal coronary artery angioplasty
4 Carotid endarterectomy
If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:
"Battle sign" is an indication of a:
skull injury- A bruise behind the ear of a trauma patient is called Battle sign, and is an important sign of a skull injury.
Kernig's sign indicates
a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
1 raccoon's eyes and Battle sign.
2 nuchal rigidity and Kernig's sign.
3 motor loss in the legs that exceeds that in the arms.
4 pupillary changes.
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?
A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?
1 Epidural hematoma
2 Acute subdural hematoma
3 Chronic subdural hematoma
4 Grade 1 concussion
Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma.
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
1 Lung auscultation and measurement of vital capacity and tidal volume
2 Evaluation for signs and symptoms of increased intracranial pressure (ICP)
3 Evaluation of pain and discomfort
4 Evaluation of nutritional status and metabolic state
In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
1 Absence of reflexes along with flaccid extremities
2 Positive Babinski's reflex along with spastic extremities
3 Hyperreflexia along with spastic extremities
4 Spasticity of all four extremities
During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
1 Mild TBI.
2 Moderate TBI.
3 Severe TBI.
4 3Brain death.
A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
the sudden, involuntary jerking of a muscle or group of muscles
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?
1 Extradural hematoma
2 Epidural hematoma
3 Subdural hematoma
4 Intracranial hematoma
An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?
1 Irrigates the wound to remove debris
2 Administers an oral analgesic for pain
3 Administers acetaminophen (Tylenol) for headache
4 Shaves the hair around the wound
Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.
a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles
Acute inflammatory condition involving the spinal nerve roots, peripheral nerves and possibly cranial nerve.
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?
1 Antibodies are removed from the plasma.
2 The thymus gland is removed.
3 Immune globulin is given intravenously.
4 Mestinon therapy is initiated.
Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?
1 "Don't worry; your child will be fine."
2 "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly."
3 "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
4 "It's too early to give a prognosis."
The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits. Telling the parents not to worry dismisses their feelings and does not address their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but it does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
1 Intracerebral hemorrhage
2 Epidural hematoma
3 Extradural hematoma
4 Subdural hematoma
A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?
1 client maintains mechanical ventilation with minimal mucus accumulation
2 client reports no discomfort
3 client's skin remains clean, dry, and intact
4 client regains bowel elimination capacity
A client with a lumbar spinal injury would not require mechanical ventilation.
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
1 Increased pulse
2 Decreased respirations
3 Widened pulse pressure
4 Decreased body temperature
Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations become rapid, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
1 Administering zolpidem tartrate (Ambien)
2 Assessing laboratory test results as ordered
3 Placing the client in Trendelenburg's position
4 Monitoring the patency of an indwelling urinary catheter
A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.
patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above)
A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
1 Administer oxygen as prescribed.
2 Use mechanical ventilation.
3 Maintain a patent airway.
4 Suction the airway.
Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions. To prevent hypoxemia, the client may need more oxygen than is available in the room air. An endotracheal tube provides an airway from the nose or mouth to an area above the mainstem bronchi. Mechanical ventilation provides a means to regulate the respiratory rate, volume of air, and percentage of oxygen when a client fails to breathe independently.
Which are characteristics of autonomic dysreflexia?
1 severe hypertension, slow heart rate, pounding headache, sweating
2 severe hypotension, tachycardia, nausea, flushed skin
3 severe hypertension, tachycardia, blurred vision, dry skin
4 severe hypotension, slow heart rate, anxiety, dry skin
Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
1 So that the patient will not have a respiratory arrest
2 Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
3 To increase cerebral perfusion pressure
4 To prevent secondary brain injury
Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
Which is the most common cause of acute encephalitis in the United States?
1 Western equine bacteria
2 Herpes simplex virus (HSV)
3 Lyme Disease
4 Human immunodeficiency virus (HIV)
Which of the following is considered a central nervous system (CNS) disorder?
1 Multiple sclerosis
3 Myasthenia gravis
4 Bell's palsy
Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
1 Speeds nerve impulse transmission
2 Carries message to the next nerve cell
3 Represents building block of nervous system
4 Acts as chemical messenger
Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.
A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor?
1 Streptococcus pneumoniae
2 Escherichia coli
3 Haemophilus influenzae
4 Staphylococcus aureus
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
1 Cardiovascular system
2 Respiratory system
3 Endocrine system
4 Neurovascular system
The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
1 Place the patient in the supine position.
2 Administer diphenhydramine (Benadryl) for the allergic reaction.
3 Administer atropine to control the side effects of edrophonium.
4 Call the rapid response team because the patient is preparing to arrest.
A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take?
1 Assess the patient's sensitivity to light.
2 Support the patient's neck through normal range of 3 motion and evaluate stiffness.
3 Help the patient flex his neck and observe for flexion of the hips and knees.
4 Flex the patient's thigh on his abdomen and assess the extension of the leg.
A positive Brudzinski sign: When the patient's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity.
A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?
1 Glucose in the CSF
2 Elevated protein levels in the CSF
3 Red blood cells present in the CSF
4 White blood cells in the CSF
A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?
1 Multiple sclerosis
2 Myesthenia gravis
3 Parkinson's disease
4 Huntington's disease
Early signs include stiffness, referred to as rigidity, and tremors of one or both hands, described as pill-rolling (a rhythmic motion of the thumb against the fingers). The hand tremor is obvious at rest and typically decreases when movement is voluntary, such as picking up an object. Bradykinesia, slowness in performing spontaneous movements, develops. Clients have a masklike expression, stooped posture, hypophonia (low volume of speech), and difficulty swallowing saliva. Weight loss occurs. A shuffling gait is apparent, and the client has difficulty turning or redirecting forward motion. Arms are rigid while walking. These symptoms are not indicative of MS, Myesthenia gravis, or Huntington's.
The nurse teaches the client that corticosteroids will be used to treat his brain tumor to
1 prevent extension of the tumor.
2 facilitate regeneration of neurons.
3 reduce cerebral edema.
4 identify the precise location of the tumor.
Which term is used to describe edema of the optic nerve?
4 Angioneurotic edema
Papilledema is edema of the optic nerve. Scotoma is a defect in vision in a specific area in one or both eyes. Lymphedema is the chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary dissection. Angioneurotic edema is a condition characterized by urticaria and diffuse swelling of the deeper layers of the skin.
Which medication classification should be avoided in the treatment of brain tumors?
2 Osmotic diuretics
Anticoagulants usually are not prescribed because of the risk for central nervous system (CNS) hemorrhage; however, prophylactic therapy with low-molecular-weight heparin is under investigation. Osmotic diuretics, corticosteroids, and anticonvulsants are utilized in the treatment of brain tumors.
sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?
1 Rapid, jerky, involuntary movements
2 Slow, shuffling gait
3 Dysphagia and dysphonia
The most prominent clinical features of the disease are chorea (rapid, jerky, involuntary, purposeless movements), impaired voluntary movement, intellectual decline, and often personality changes
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition?
1 Hemorrhagic stroke
2 Thyroid disorders
3 Hearing loss
4 Visual loss
Brain angiomas (masses composed largely of abnormal blood vessels) are found either in the brain or on its surface. Because the walls of the blood vessels in angiomas are thin, affected clients are at risk for hemorrhagic stroke. Pituitary adenomas that produce hormones can lead to endocrine disorders, such as thyroid disorders. In addition, they can exert pressure on the optic nerves and optic chiasm, leading to vision loss. Acoustic neuromas are associated with hearing loss.
nosocomial infection means?
hospital acquired infection
You are caring for a client with an impaired immune system. You are concerned about the client acquiring a nosocomial infection. What intervention would help nurses control nosocomial infections?
1 Apply principles of medical and surgical asepsis.
2 Maintain a proper diet and exercise regimen.
3 Use proper antibiotics.
4 Ensure childhood immunizations.
The nurse observes a physician leave the room of a client in isolation for infection with Clostridium difficile. The physician uses the alcohol-based hand sanitizer hanging on the wall to wash her hands and leaves the door open. Which action should the nurse take?
1 No action is needed. The physician was following isolation protocol.
2 Ask the physician to wash her hands with soap and water.
3 Close the door to the room.
4 Report the observation to the infection control department.
C. difficile is resistant to alcohol-based and other hand sanitizers; therefore physicians should be instructed to wash their hands with soap and water. The nurse could report the observation to the infection control department, but that does not address the immediate concern of the physician contaminating other clients. There is no need for the room door to be closed. The nurse must take action to ensure the safety of other clients.
The nurse is caring for a patient with a meningococcus infection. What type of precautions should be used for this patient?
Droplet precautions are used for organisms such as influenza or meningococcus that can be transmitted by close contact with respiratory or pharyngeal secretions.
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
1 Rashes on the palms of the hands and soles of the feet
2 Cauliflower-like warts on the penis
3 Painful red papules on the shaft of the penis
4 Foul-smelling discharge from the penis
Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.
Examples of airborne diseases:
TB, measles, chicken pox (Varicella Zoster)
Herpes Zoster (Shingles)
Which term refers to a state of microorganisms being present within a host without causing host interference or interaction?
Understanding the principle of colonization facilitates interpretation of microbiologic reports. A susceptible host is one that does not possess immunity to a particular pathogen. An immune host is one that is not susceptible to a particular pathogen. Infection refers to host interaction with an organism.
______________: condition in which the host interacts physiologically and immunologically with a microorganism
_______________: not possessing immunity to a particular pathogen
_________: an organism that provides living conditions to support a microorganism
_________: person with protection from a previous infection or vaccination who resists reinfection when re-exposed to the same agent
Which of the following is the gold standard for herpes simplex virus (HSV) diagnosis?
2 Shave biopsy
3 Excisional biopsy
4 Punch biopsy
The gold standard for HSV diagnosis is a culture of the lesion. Serology may help determine new versus chronic infection when obtained concurrently with positive culture of the lesion. The other diagnostics may be used for diagnosis of skin disorders, but would not be used for HSV.
A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?
1 Food poisoning
2 An allergic reaction to the antibiotic
3 A helminth infection
4 Pseudomembranous colitis
When a client is taking an antibiotic, a superinfection can result from overgrowth of microorganisms not affected by the drug. This can lead to a serious inflammation of the colon called pseudomembranous colitis accompanied by potentially life-threatening diarrhea. Report fever, abdominal cramps, and severe diarrhea immediately. The other distractors are incorrect and not related to the use of the antibiotics.
Painless chancres are associated with which systemic disease?
1 Kaposi sarcoma
Syphilis is manifested by a painless chancres. Psoriasis is exhibited by plaques with scales. Kaposi sarcomas are cutaneous lesions that are blue-red or dark brown in color. Urticaria is wheals or hives due to infection or allergic reactions.
The nurse is assessing a client who states having had "unusual aches" in the muscles and joints. On physical examination, the nurse notes the client has rough, reddish-brown spots on the palms and the soles of the feet. The client reports being infected with a "cold sore" from her partner 1 month ago. What should the nurse anticipate will be the next step in this client's care?
1 A prescription for a nontreponemal test (NTT)
2 A prescription for a topical antibiotic
3 Obtaining a culture from the rash covered areas
4 Administration of pain medication
A client who is blind is admitted for treatment of gastroenteritis. What does the nurse recognize as the highest priority for this client?
1 Fluid volume deficit
2 Risk for injury
3 Activity intolerance
4 Limited mobility
Because the client has gastroenteritis and is probably dehydrated, the client's fluide volume takes highest priority. A sensory deficit such as blindness puts the client at risk for injury from the environment; however, a potential problem doesn't take highest priority. Although the client's tolerence for activity and mobility also may be relevant, these don't take precedence over the client's dehydration.
The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?
An opportunistic or superinfection occurs among immunocompromised hosts. Examples would be yeast infections in the mouth, bladder infections, gastroenteritis, and Pneumocystis carinii. An acute infection has a sudden onset with serious and sometimes life-threatening manifestations. A chronic infection is an extended infection that resists treatment. A secondary infection is a complication of some other disease process that occurred first.
A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
1 An induration of 12mm
2 An uneven erythemic area
3 An induration of less than 1 mm
4 An induration of 4 mm
The size of the induration, not including the surrounding area of erythema, is measured in millimeters. The measurement determines whether the reaction is significant. For example, a tuberculin skin test is test is considered positive if the induration is 10 mm or greater in persons with no known risk factors for TB; smaller measurements are significant in certain risk groups, such as immunocompromised clients. The other answers are not indicative of positive results.
Which stage or period of syphilis occurs when the infected person has no signs or symptoms of syphilis?
Secondary syphilis occurs when the hematogenous spread of organisms from the original chancre leads to generalized infection. A period of latency occurs when the infected person has no signs or symptoms of syphilis. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. Tertiary syphilis presents as a slowly progressive inflammatory disease with the potential to affect multiple organs.
A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?
__________ syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. These lesions usually resolve spontaneously within 3 to 12 weeks, with or without treatment
__________ syphilis occurs when the hematogenous spread of organisms from the original chancre leads to generalized infection. The rash of secondary syphilis occurs from 1 week to 6 months after the chancre and involves the trunk and the extremities, including the palms of the hands and the soles of the feet
After the secondary stage, there is a period of ____________ when the person who is infected has no signs or symptoms of syphilis. Latency can be interrupted by a recurrence of secondary syphilis symptoms.
___________ stage of syphilis presents as a slowly progressive inflammatory disease with the potential to affect multiple organs. The most common manifestations at this level are aortitis and neurosyphilis, as evidenced by dementia, psychosis, paresis, stroke. May occur 10 years or more after infection.
A forcible pulling away of a part or structure
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?
1 Diagnostic and laboratory testing
2 Assessment of peripheral pulses
3 Establishing a patent airway
4 Undressing the client
Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.
A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.
Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left.
The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action?
1 Administer analgesic medications as ordered.
2 Keep the hand in the circulating bath for 1 hour.
3 Rupture any hemorrhagic blebs that are noted.
4 Have the client complete active range-of-motion exercises.
During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored
The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the nextrequired action?
1 Remove the peripheral IV line
2 Start a dextrose 5% water infusion
3 Run a normal saline line to keep the vein open
4 Obtain a blood culture from the IV insertion site
A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
2 Pale, warm, dry skin
3 Heart rate of 70 beats/minute
4 Elevated blood pressure
Early in shock, inadequate perfusion leads to anaerobic metabolism, which causes metabolic acidosis. As the respiratory rate increases to compensate, the client's carbon dioxide level decreases, causing alkalosis and subsequent confusion and combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.
Permanent brain injury or death will occur within which time frame secondary to hypoxia?
1 1 to 2 minutes
2 3 to 5 minutes
3 6 to 8 minutes
4 9 to 10 minutes
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?
1 Providing an analgesic for pain
2 Massaging the feet
3 Restricting ambulation
4 Placing sterile cotton between the toes after rewarming
For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.
The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV?
4 Upper arm
PIV lines should rarely be used in the foot for various reasons. They limit the client's ability to ambulate and tend to occlude easily. These types of IVs should never be used in clients with diabetes due to the risk that the client has neuropathy and cannot feel injury caused by the IV catheter. IV lines in the forearm and hands are acceptable and are commonly used sites. These sites would be safe to use for a client with diabetes. The upper arm is a site of choice for the insertion of a peripherally inserted central line (PICC) not a PIV line. Although, this site would not be an option for a PIV line, it would be safe for use in a client with diabetes if warranted.
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?
1 Temperature of 101 degrees F (38 degrees C)
Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.
A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next?
1 Encourage the client to cough forcefully.
2 Insert a nasopharyngeal airway.
3 Prepare the client for a bronchoscopy.
4 Insert an oropharyngeal airway.
If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the client demonstrates a weak, ineffective cough, a high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the client should be managed as if there were complete airway obstruction. If the client is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.
You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first?
1 The one who ingested the toxin
2 The one who inhaled the toxin
3 The one with the skin infection
4 Any convenient order
The nurse should first treat the client who is at greatest risk. The most serious form of anthrax develops upon inhalation. If diagnosed incorrectly and untreated, the infection progresses to severe respiratory distress, and in severe situations, death may also occur. Ingesting the bacteria is less lethal, with symptoms of nausea, vomiting, diarrhea, and abdominal pain. Skin infection is the least deadly form characterized by painless lesions usually on the head, hands, and arms. Therefore, the client who inhaled the toxin should always get first priority.
The nurse is working with a victim suffering from blast lung and resultant air emboli. The nurse should immediately place the victim in which position?
1 Prone left lateral
2 Supine right lateral
3 High Fowler
The nurse should immediately place the victim in the prone left lateral position to prevent migration of the embolus. The victim will also require emergent treatment in a hyperbaric chamber.
When describing the use of smallpox as a biologic agent, which of the following would the nurse include as the primary means of infection?
3 Direct contact
4 Percutaneous absorption
Triage colors and meanings?
red-critically wounded- chest wound, airway obstruction
yellow-wounded but can wait for help wait 1-2 hr
green-can walk. fractures, minor burns
black-dead/ not likely to survive. burns 60% of body, spinal injury
The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care?
1 Blast lung
2 Tympanic rupture
3 Head injury
4 Abdominal injury
The nurse should prepare to care for a client with probable tympanic rupture. Signs and symptoms of tympanic rupture include hearing loss, tinnitus, pain, dizziness, and otorrhea. Symptoms of blast lung include dyspnea, hypoxia, tachypnea or apnea, cough, chest pain, and hemodynamic instability. Symptoms of head injury include postconcussive syndrome. Symptoms of abdominal injury include pain, guarding, rebound tenderness, rectal bleeding, nausea, and vomiting.
Which is the most likely weaponized biological agent available?
The nurse administers mannitol to the client with IICP. Which parameter requires close monitoring?
A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynauds phenomenon. The nurse will anticipate teaching the patient about tests for
What is the humeroulnar joint? What it is function?
how should the physician wrap the patient's affected arm with soaked casting for a short-arm cast?
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