Exam 4

Question 1

Increased Intracranial Pressure signs and symptoms?

Answer 1

N&V, LOC changes, blurred vision, headache

Question 2

Your patient is ventilated and has sudden anxious episode and is trying to fight the ventilator, Nursing intervention?

Answer 2

Instruct the client to breathe with the ventilator.
Check the O2 saturation (Concern: hypoxia)

Question 3

Your patient is trying to cough and the secretions are too thick, What are your nursing interventions?

Answer 3

Humidify the air, increase fluids

Question 4

A patient arrives and you suspect that he has neurogenic shock, what are your immediate nursing interventions?

Answer 4

100% nonrebreather
C-Collar
avoid lactated ringers
monitor vital signs (BP & T)
administer atropine (to increase heart rate.)

Question 5

What can low platelets and presence of petechia indicate?

Answer 5

Bleeding and not clotting.
Condition: DIC is forming
Concern: organ failure

Question 6

Vasopressor side effects to be concerned with?

Answer 6

Chest pain, decreased HR, weakened pulses.
Decreased urine output is normal when patient is taking vasopressor

Question 7

Priority with any shock patient

Answer 7

Airway support à 100% non-rebreather mask oxygen

Question 8

What signs and symptoms characterize neurogenic shock compared to the other shocks?

Answer 8

Decreased HR, decreased BP

Question 9

What is the first nursing action when your patient has a fat embolism?

Answer 9

Assess the O2 saturation and put O2 on the patient

Question 10

What is an outcome of Cooley’s fracture to be looking for?

Answer 10

Decreased cap refill (>3 seconds)

Question 11

1 thing to do for a meniscus injury?

Answer 11

Apply an immobilizer to the affected knee.

Question 12

What does prolonged cap refill indicate on your patient?

Answer 12

Compartment syndrome à Notify the HC

Question 13

Priority assessment of a patient who has had an ORIF?

Answer 13

Patient is at risk for infection -osteomyelitis

Question 14

Patient has surgery and starts to develop S/S of tachycardia, tachypnea, decreased O2 saturation, and SOB, what are you concerned about?

Answer 14

Pulmonary embolism -100% O2 Nonrebreather mask.

Question 15

When does acute back pain typically start to improve?

Answer 15

2 weeks or 7-14 days

Question 16

Patient education for a patient with low back pain?

Answer 16

Firm mattress, bend with the knees, maintain appropriate body weight, no smoking, on side with pillow between knees, no stomach sleeping

Question 17

What can a patient take to relieve back pain?

Answer 17

NSAIDS

Question 18

Metastatic bone cancer interventions

Answer 18

Give sustained release long-acting opioids
monitor serum calcium (will be increased)
when turning the patient, hold the leg in place/ immobilize it.

Question 19

What is the prognosis for metastatic bone cancer?

Answer 19

Not good.

Monitor patient’s psychosocial needs and provide support to patient and family.

Question 20

Your patient just had surgery and is having difficulty voiding, what is your biggest concern?

Answer 20

Damage to one of the spinal nerves during surgery

Question 21

Your patient presents with neck pain and numbness and tingling, what would you assess for?

Answer 21

If there is a compromise in the nerve root, or nerve damage

Question 22

S/S of osteomyelitis

Answer 22

Fever, bone pain.

Question 23

What are some proper body mechanics for the back?

Answer 23

Bend at waist, lift with knees, do not twist, feet shoulder width apart, items close to them.

Question 24

An older patient has osteoporosis, what would you see in your patient?

Answer 24

Shortened height, kyphosis (hunchback)

Question 25

What would you assess with your patient prior to surgery?

Answer 25

If they are taking any supplements and if they are taking any medication.
Herbs that start with G

Question 26

What are the problems that would make you prioritize a patient?

Answer 26

Hypotension, airway compromise, bleeding, change in level of consciousness, dizziness, increased temp (>100.4), complaints of severe pain.

Question 27

Is it normal for a patient to have a low grade temp after surgery?

Answer 27

YES, give analgesic like Tylenol.

Question 28

A patient returns to the floor after surgery and you see the wound is dehiscence, is this a priority patient?

Answer 28

yes

Question 29

What lab value would you assess for wound healing?

Answer 29

Albumin (Protein)

Question 30

Cushing’s triad

Answer 30

Widened pulse pressure, bradycardia, hypertension, respiratory changes

Question 31

How do you assess CSF fluid?

Answer 31

Nose swab of the drainage-positive for glucose

Question 32

Treatment for epidural hematoma

Answer 32

Surgery

Question 33

How do you prevent meningitis?

Answer 33

Vaccinations

Question 34

Patient presents with intracerebral hemorrhage and unilateral weakness, what should you assess about your patient?

Answer 34

Are they taking any blood thinners?

Question 35

Your patient has a stroke, and is ordered to have aspirin, when would you hold the patient?

Answer 35

If the patient has a headache, could be pressure from bleeding in the brain.
Aspirin is always contraindicated with bleeding

Question 36

Nursing actions for a T2 spinal injury

Answer 36

This patient would be a paraplegic.
Urinary catheter
cardiac monitoring
H2 receptor blockers (-tidine, -dine)
monitor for poikilothermia.

Question 37

Trigeminal neuralgia

Answer 37

Cranial nerve 5
Main reported clinical manifestation is facial discomfort or pain

Question 38

Bell’s palsy

Answer 38

Cranial nerve 7.

Question 39

Priority for a patient with a C5 spinal cord injury?

Answer 39

Respiratory, airway

Question 40

How to limit the development of SIRS

Answer 40

Prevent infection– sepsis
Hand hygiene, remove the urinary catheter as soon as possible, ambulate as soon as possible.

Question 41

Your patient develops pre-syncope, what are your nursing actions?

Answer 41

fall precautions
Pre-syncope: give something to drink, take VS, call the HCP

Question 42

What can you delegate to a UAP preop?

Answer 42

VS, CHG bathing, transportation