Exam 4

Question 1

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?

a. An 18-year-old college student with type 1 diabetes who exercises excessively
b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections
d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza

Chapter 18 #2

Answer 1

d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza

Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would result in further increases in blood sugar. Some individuals with advanced Alzheimer’s disease cannot communicate thirst needs and may be incontinent, making hypertonic fluid loss more difficult to estimate. Uncontrolled type 1 diabetes is associated with diabetic ketoacidosis. Interruption of insulin delivery related to a missed insulin dose in type 1 diabetes creates a situation of absolute insulin deficiency in type 1 diabetes and is associated with diabetic ketoacidosis. A patient with type 2 diabetes who is new to insulin is at risk for hypoglycemia.

Question 2

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is:

a. 70 to 120 mg/dL.
b. a decrease of 25 to 50 mg/dL compared with admitting values.
c. a decrease of 50 to 75 mg/dL compared with admitting values.
d. less than 200 mg/dL.

Chapter 18 #5

Answer 2

c. a decrease of 50 to 75 mg/dL compared with admitting values.

Initial insulin infusions should be administered with a target blood glucose reduction of 50 to 75 mg/dL per hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus, controlled reduction of glucose is required.

Question 3

A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring?

a. Calcium
b. Chloride
c. Potassium
d. Sodium

Chapter 18 #10

Answer 3

c. Potassium

Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid balance has been restored and glucose has returned to more normal levels. Insulin administration used in the treatment of diabetic ketoacidosis further promotes lowering of potassium as the electrolyte is relocated to the cellular bed. Calcium levels do not drastically change in hyperosmolar states and are not a primary concern unless phosphate replacement is initiated. Chloride levels typically follow sodium levels and normalize with fluid replacement. Sodium levels may initially be elevated as a result of dehydration but will be corrected with fluid replacement.

Question 4

The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patient’s urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing:

a. diabetes insipidus.
b. diabetic ketoacidosis.
c. hyperosmolar hyperglycemic syndrome.
d. syndrome of inappropriate secretion of antidiuretic hormone.

Chapter 18 #7

Answer 4

a. diabetes insipidus.

Diabetes insipidus results in large volumes of urine; dehydration and hypovolemia can result. Head trauma and resulting increased intracranial pressure are potential causes of diabetes insipidus. High urine output following head trauma is associated with diabetes insipidus. Even though hyperosmolar hyperglycemic syndrome results in osmotic diuresis, the cause is a deficiency in insulin in type 2 diabetes, not head trauma. SIADH may occur with head trauma but results in reduced urine output and, potentially, hypervolemia.

Question 5

An individual with type 2 diabetes who takes glipizide (Glucotrol) to control her blood glucose has begun a formal exercise program at a local gym. While exercising on the treadmill, she becomes pale, diaphoretic, and shaky. She has a headache and feels as though she is going to pass out. What is the individual’s priority action?

a. drink additional water to prevent dehydration
b. Eat something with 15 g of simple carbohydrates.
c. Go to the first aid station to have glucose checked.
d. Take another dose of the oral agent.

Chapter 18 #14

Answer 5

b. Eat something with 15 g of simple carbohydrates.

The patient is displaying classic symptoms of hypoglycemia. The patient is on sulfonylurea therapy, which carries the risk of hypoglycemia. The walking may be more exercise than she is used to and may thereby cause hypoglycemia. Fifteen grams of carbohydrate is appropriate for initial management of hypoglycemia. Hypoglycemia does not place the patient at risk for dehydration. The patient requires immediate treatment and could pass out while going to the first aid station. It cannot be assumed that the gym has access to diabetes treatment supplies. Additional doses of oral diabetes medications should not be taken without consulting the healthcare team. An additional dose of glipizide could promote further hypoglycemia.

Question 6

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started?

a. Never; normal saline is the only appropriate solution in diabetes management
b. When the blood sugar reaches 70 mg/dL
c. When the blood sugar reaches 150 mg/dL
d. When the blood glucose reaches 250 mg/ dL

Chapter 18 #9

Answer 6

d. When the blood glucose reaches 250 mg/ dL

Normal saline is the best initial fluid choice for management of hyperglycemic states. However, when the glucose reaches about 250 mg/dL, solutions containing dextrose are added to prevent hypoglycemia. Hypotonic solutions are required to replace intracellular fluid deficits, and dextrose is required to prevent hypoglycemia later when glucose levels reach initial targets. A glucose level of 70 mg/dL is suggestive of hypoglycemia and would require oral glucose replacement, a 50% dextrose bolus, or glucagon administration.

Question 7

An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis?

a. Elevated adrenocorticotropic hormone
b. Elevated cortisol levels
c. Elevated T3 and T4
d. Elevated thyroid-stimulating hormone

Chapter 18 #19

Answer 7

d. Elevated thyroid-stimulating hormone

Thyroid hormones are low in myxedema. Thyroid-stimulating hormone is usually high in relation to the feedback mechanisms for hormone regulation if myxedema is caused by primary hypothyroidism. Elevated adrenocorticotropic hormone may be seen in pituitary conditions or adrenal insufficiency. Elevated cortisol levels accompany Cushing’s syndrome. Elevated T3 and T4 levels are consistent with hyperthyroidism.

Question 8

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient?

a. Atrial fibrillation
b. Idioventricular rhythm
c. Junctional rhythm
d. Sinus bradycardia

Chapter 18 #18

Answer 8

a. Atrial fibrillation

Increased heart rate and tachydysrhythmia, including atrial fibrillation, may accompany thyroid storm. Bradycardiac rhythms may be suggestive of hypothyroidism.

Question 9

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient’s plan of care?

a. Frequent neurological assessments
b. Side to side position changes
c. Range of motion to extremities
d. Frequent oropharyngeal suctioning

Chapter 13 #1

Answer 9

a. Frequent neurological assessments

Nurses complete neurological assessments based on ordered frequency and the severity of the patient’s condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patient’s plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient’s plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated.

Question 10

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient’s left naris. What is the best nursing action?

a. Have the patient blow the nose until clear.
b. Insert bilateral cotton nasal packing.
c. Place a nasal drip pad under the nose.
d. suction the left nares until the drainage clears

Chapter 13 #5

Answer 10

c. Place a nasal drip pad under the nose.

In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

Question 11

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw- colored drainage from the left nare. What is the most appropriate nursing action?

a. Insert bilateral ear plugs.
b. Monitor airway patency.
c. Maintain neutral head position.
d. Apply a small nasal drip pad.

Chapter 13 #11

Answer 11

d. Apply a small nasal drip pad.

Patient assessment findings are indicative of a skull fracture. The presence of straw- colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.

Question 12

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?

a. Altered cerebral spinal fluid production and reabsorption
b. Decreased cerebral blood volume due to vessel constriction
c. Increased cerebral blood volume due to vessel dilation
d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

Chapter 13 #8

Answer 12

c. Increased cerebral blood volume due to vessel dilation

Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.

Question 13

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg
b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg
c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

Chapter 13 #14

Answer 13

c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg

Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a
PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35-45) can lead to
cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.

Question 14

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)?

a. Ensure adequate periods of rest between nursing interventions.
b. Insert an oral airway and monitor respiratory rate and depth.
c. Maintain neutral head alignment and avoid extreme hip flexion.
d. Reduce ambient room temperature and administer antipyretics.

Chapter 13 #12

Answer 14

d. Reduce ambient room temperature and administer antipyretics.

In this scenario, the patient’s temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

Question 15

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95%
on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which physician order should the nurse institute first?

a. Blood cultures (2 specimens) for temperature > 101° F
b. Acetaminophen (Tylenol) 650 mg per rectum
c. 500 mL albumin infusion intravenously
d. Decadron 20 mg intravenous push every 4 hours

Chapter 13 #22

Answer 15

c. 500 mL albumin infusion intravenously

Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

Question 16

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma
Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority?

a. Lasix 20 mg intravenous push as needed
b. 500 mL albumin intravenous infusion
c. Decadron 10 mg intravenous push
d. Dilantin 50 mg intravenous push

Chapter 13 #29

Answer 16

b. 500 mL albumin intravenous infusion

To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.

Question 17

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2)
96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first?

a. Obtain stat serum electrolytes.
b. Administer lorazepam (Ativan).
c. Obtain stat portable chest x-ray.
d. Administer phenytoin (Dilantin).

Chapter 13 #25

Answer 17

b. Administer lorazepam (Ativan).

The nurse should administer lorazepam (Ativan) as ordered; lorazepam (Ativan) is the first-line medication for the treatment of status epilepticus. Phenytoin (Dilantin) is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

Question 18

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse?

a. Implement droplet precautions upon admission.
b. Wash hands thoroughly before leaving the room.
c. Scrub the hub of all central line ports prior to use.
d. Dispose of all bloody dressings in biohazard bags.

Chapter 13 #31

Answer 18

a. Implement droplet precautions upon admission.

Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection.
Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

Question 19

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen
at 3 L/min, and a temperature 103.5° F. What is the priority nursing action?

a. Elevate the head of the bed 30 degrees.
b. Keep lights dim at all times.
c. Implement seizure precautions.
d. Maintain bedrest at all times.

Chapter 13 #32

Answer 19

c. Implement seizure precautions.

Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation such photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bedrest are all appropriate nursing interventions but are not the priorities in this scenario.

Question 20

A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy?

a. Aspiration pneumonia and sepsis
b. Fluid and electrolyte imbalances and sepsis
c. Fluid overload and pulmonary edema
d. Hypoglycemia and renal insufficiency

Chapter 6 #1

Answer 20

b. Fluid and electrolyte imbalances and sepsis

Because of the high dextrose concentration, including the fluid and electrolyte content, the patient is placed at high risk for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a potential complication of enteral feedings; sepsis is a potential complication of parenteral nutrition. Fluid overload is possible but unlikely and is not a major complication of parenteral nutrition. Hyperglycemia is more of a concern than hypoglycemia with parenteral nutrition; however, renal insufficiency is not related to parenteral nutrition.

Question 21

A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care?

a. Change the intravenous tubing every 24 hours.
b. Infuse antibiotics through the intravenous line.
c. Monitor the blood glucose every 6 hours.
d. Monitor the fluid and electrolyte balance.

Chapter 6 #11

Answer 21

b. Infuse antibiotics through the intravenous line.

Medications should not be infused through the IV line infusing parenteral nutrition.

Question 22

A patient is receiving enteral tube feedings and has developed drug- nutrient interactions. The nurse recognizes which drug as having the potential for causing drug-nutrient reactions?

a. Aspirin
b. Enoxaparin
c. Ibuprofen
d. Phenytoin

Chapter 6 #13

Answer 22

d. Phenytoin

Bioavailability of phenytoin is reduced when administered with enteral feedings.

Question 23

The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following?

a. Assess for signs of peptic ulcer.
b. Be watchful for increased saliva production.
c. Evaluate for a decrease in potassium level.
d. Give the patient medications to prevent anemia.

Chapter 17 #4

Answer 23

a. Assess for signs of peptic ulcer.

Secretion of mucus by Brunner’s glands is inhibited by sympathetic stimulation, which leaves the duodenum unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract is the site for more than 50% of peptic ulcers. Sympathetic stimulation produces a scant output of thick saliva. Vitamin B12 is critical
for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia. However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium, potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk for fluid and electrolyte imbalances and acid-base disturbances. However, nothing indicates that the patient is vomiting or has GI suction.

Question 24

The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient:

a. has a 99% chance of survival.
b. has a 15% chance of dying.
c. has a 40% chance of dying.
d. has no chance of survival.

Chapter 17 #35

Answer 24

b. has a 15% chance of dying.

Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient’s chance of significant morbidity and mortality. In Ranson’s research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

Question 25

The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that:

a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa.
b. this type of bleeding is treated by giving chewable aspirin.
c. the bleeding, although impressive, is self- limiting with little actual blood loss.
d. is not usually associated with alcohol intake or retching.

Chapter 17 #18

Answer 25

a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa.

A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal antiinflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair.

Question 26

The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patient’s calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and:

a. places the patient on seizure precautions.
b. expects that the provider will come and remove the endotracheal tube.
c. withhold any further calcium treatments.
d. place an oral airway at the bedside.

Chapter 17 #37

Answer 26

a. places the patient on seizure precautions.

Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low and replacement of calcium is expected.

Question 27

The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurse’s first action should be to:

a. measure abdominal girth to determine the amount of fluid accumulation.
b. position the patient in a semi-Fowler’s position.
c. prepare the patient for emergent paracentesis.
d. administer diuretics.

Chapter 17 #44

Answer 27

b. position the patient in a semi-Fowler’s position.

Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowler’s position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowler’s position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.

Question 28

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia

Brunner 68 #3

Answer 28

B) Bradycardia and hypertension

Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (“goose bumps”), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

Question 29

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?

A) Check the patient’s indwelling urinary catheter for kinks to ensure patency.
B) Lower the HOB to improve perfusion.
C) Administer analgesia.
D) Reassure the patient that headaches are expected after spinal cord injuries.

Brunner 68 #14

Answer 29

A) Check the patient’s indwelling urinary catheter for kinks to ensure patency

A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the patient’s catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.

Question 30

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse’s best answer?

A) “The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.”
B) “The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state.”
C) “Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing.”
D) “The sudden, severe headache increases muscle tone and can cause further nerve damage.”

Brunner 68 #34

Answer 30

A) “The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.”

The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

Question 31

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?

A) Risk for impaired skin integrity
B) Risk for injury
C) Risk for autonomic dysreflexia
D) Risk for suffocation

Brunner 68 #2

Answer 31

B) Risk for injury

If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient’s neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

Question 32

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

A) Sports-related injuries
B) Acts of violence
C) Injuries due to a fall
D) Motor vehicle accidents

Brunner 68 #7

Answer 32

D) MVA

The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%).

Question 33

A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply.

A) Orthostatic hypotension
B) Autonomic dysreflexia
C) DVT
D) Salt-wasting syndrome
E) Increased ICP

Brunner 68 #38

Answer 33

A) Orthostatic hypotension
B) Autonomic dysreflexia
C) DVT

For a spinal cord-injured patient, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not typical complications following the immediate recovery period.

Question 34

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

A) Epistaxis
B)Periorbital edema
C)Bruising over the mastoid
D)Unilateral facial numbness

Brunner 68 #1

Answer 34

C) Bruising over the mastoid

An area of ecchymosis (bruising) may be seen over the mastoid (Battle’s sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

Question 35

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply

A) The ability to select medications for the neurologic dysfunction
B) Understanding of the tests used to diagnose neurologic disorders
C) Knowledge of nursing interventions related to assessment and diagnostic testing
D) Knowledge of the anatomy of the nervous system
E) The ability to interpret the results of diagnostic tests

Brunner 65 #24

Answer 35

B) Understanding of the tests used to diagnose neurologic disorders
C) Knowledge of nursing interventions related to assessment and diagnostic testing
D) Knowledge of the anatomy of the nervous system

Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

Question 36

The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patient’s level of consciousness (LOC)?

A) Assess the patient’s vital signs and correlate these with the patient’s baselines
B) Assess the patient’s eye opening and response to stimuli
C) Document that the patient currently lacks a level of consciousness
D) Facilitate diagnostic testing in an effort to obtain objective data.

Brunner 65 #37

Answer 36

B) Assess the patent’s eye opening and response to stimuli

If the patient is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the patient’s LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.

Question 37

The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized?

A) Achieve as high a level of function as possible
B) Enhance the quantity of the patient’s life
C) Teach the family proper care of the patient
D) Provide community assistance.

Brunner 66 #21

Answer 37

A) Achieve as high a level of function as possible

The overarching goals of care are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. This goal encompasses family and community participation.

Question 38

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

A) To decrease cerebral edema
B) To prevent seizure activity that is common following a TIA
C) To remove atherosclerotic plaques blocking cerebral flow
D) To determine the cause of the TIA

Brunner 67 #2

Answer 38

C) To remove atherosclerotic plaques blocking cerbral flow

The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

Question 39

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient’s admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient’s plan of care?

A) Elevate the head of the bed to 45 degree
B) Maintain the patient on complete bed rest
C) Administer enemas when the patient is constipated
D) Avoid use of thigh-high elastic compression stockings.

Brunner 67 #12

Answer 39

B) Maintain the patient on complete bed rest

Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. No enemas are permitted, but stool softeners and mild laxatives are prescribed. Thigh-high elastic compression stockings or sequential compression boots may be ordered to decrease the patient’s risk for deep vein thrombosis (DVT).

Question 40

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?

A) Range-of-motion exercises to prevent contractures
B) Encouraging independence with ADLs to promote recovery
C) Early initiation of physical therapy
D) Absolute bed rest in a quiet, nonstimulating environment

Brunner 67 #7

Answer 40

D) Absolute bed rest in a quiet, nonstimulating environment

The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raise BP.

Question 41

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

A) Sit with the patient for a few minutes
B) Administer an analgesic
C) Inform the nurse-manager
D) Call the physician immediately.

Brunner 67 #15

Answer 41

D) Call the physician immediately

A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. The physician will decide whether administration of an analgesic is indicated. Informing the nurse-manager is not necessary. Sitting with the patient is appropriate, once the physician has been notified of the change in the patient’s condition.

Question 42

Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient’s plan of care?

A) Supervise the patient’s activities of daily living closely
B) Initiate early ambulation to prevent complications of immobility
C) Provide a high-calorie, low-protein diet
D) Perform all of the patient’s hygiene and feeding.

Brunner 67 #30

Answer 42

A) Supervise the patient’s activities of daily living closely

The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. As such, independent ADLs and ambulation are contraindicated. There is no need for a high-calorie or low-protein diet.

Question 43

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient’s cardiac and neurologic status, the nurse monitors the patient for signs of what complication?

A) Acute pain
B) Septicemia
C) Bleeding
D) Seizures

Brunner 67 #40

Answer 43

C) Bleeding

Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

Question 44

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?
A) A patient with a blunt chest trauma with some difficulty breathing
B) A patient with a sore neck who was immobilized in the field on a backboard
with a cervical collar
C) A patient with a possible fractured tibia with adequate pedal pulses
D) A patient with an acute onset of confusion

Answer 44

Ans: A
The patient with blunt chest trauma possibly has a compromised airway.
Establishment and maintenance of a patent airway and adequate ventilation is prioritized
over other health problems, including skeletal injuries and changes in cognition.

Question 45

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test?
A)	Radiograph
B)	Computed tomography (CT) scan
C)	Complete blood count (CBC)
D)	Barium swallow

Answer 45

B). CT scan.

Question 46

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
A)	Liver
B)	Small bowel
C)	Stomach
D)	Large bowel

Answer 46

Ans: B
Feedback:
Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel. The liver is also injured frequently, but it is a solid organ.

Question 47

A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient?
A) Ambulate the patient to expel flatus.
B) Place the patient in a high Fowler’s position.
C) Immobilize the patient on a backboard.
D) Place the patient in a left lateral position.

Answer 47

C) Immobilize the patient on a backboard.

Question 48

26. A patient’s health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn’s disease, rather that ulcerative colitis, as the cause of the patient’s signs and symptoms?
    A) A pattern of distinct exacerbations and remissions
    B) Severe diarrhea
    C) An absence of blood in stool
    D) Involvement of the rectal mucosa

Answer 48

C) An absence of blood in stool

Question 49

A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply.
A) Acute Pain Related to Increased Peristalsis and GI Inflammation
B) Activity Intolerance Related to Generalized Weakness
C) Bowel Incontinence Related to Increased Intestinal Peristalsis
D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea
E) Impaired Urinary Elimination Related to GI Pressure on the Bladder

Answer 49

A) Acute Pain Related to Increased Peristalsis and GI Inflammation
B) Activity Intolerance Related to Generalized Weakness
D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea

Question 50

11. A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patient’s coping after discharge?
    A) The family’s ability to take care of the patient’s special diet needs
    B) The family’s ability to monitor the patient’s changing health status
    C) The family’s ability to provide emotional support
    D) The family’s ability to manage the patient’s medication regimen

Answer 50

C) The family’s ability to provide emotional support

Question 51

2.	A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics?
A)	Watery with blood and mucus
B)	Hard and black or tarry
C)	Dry and streaked with blood
D)	Loose with visible fatty streaks

Answer 51

A) Watery with blood and mucus

Question 52

4. A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurse’s rapid assessment reveals that the patient’s abdomen is uncharacteristically rigid on palpation. What is the nurse’s best response?
   A) Administer a Fleet enema as ordered and remain with the patient.
   B) Contact the primary care provider promptly and report these signs of perforation.
   C) Position the patient supine and insert an NG tube.
   D) Page the primary care provider and report that the patient may be obstructed.

Answer 52

B) Contact the primary care provider promptly and report these signs of perforation.

Question 53

25. An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis.
    What components of treatment should the nurse anticipate? Select all that apply.
    A) Anticholinergic medications
    B) Increased fiber intake
    C) Enemas on alternating days
    D) Reduced fat intake
    E) Fluid reduction

Answer 53

B) Increased fiber intake

D) Reduced fat intake

Question 54

10. The nurse is preparing to perform a patient’s abdominal assessment.
    What examination sequence should the nurse follow?
    A) Inspection, auscultation, percussion, and palpation
    B) Inspection, palpation, auscultation, and percussion
    C) Inspection, percussion, palpation, and auscultation
    D) Inspection, palpation, percussion, and auscultation

Answer 54

A) Inspection, auscultation, percussion, and palpation

Question 55

5. A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
   A) Insertion of a nasogastric tube
   B) Insertion of a central venous catheter
   C) Administration of a mineral oil enema
   D) Administration of a glycerin suppository and an oral laxative

Answer 55

A) Insertion of a nasogastric tube

Question 56

13. A 16-year-old presents at the emergency department complaining of right lower
    quadrant pain and is subsequently diagnosed with appendicitis. When planning this
    patient’s nursing care, the nurse should prioritize what nursing diagnosis?
    A) Imbalanced Nutrition: Less Than Body Requirements Related to Decreased
    Oral Intake
    B) Risk for Infection Related to Possible Rupture of Appendix
    C) Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake
    D) Chronic Pain Related to Appendicitis

Answer 56

B) Risk for Infection Related to Possible Rupture of Appendix

Question 57

35. A patient’s large bowel obstruction has failed to resolve spontaneously and the patient’s worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?
    A) Administering bowel stimulants as ordered
    B) Administering bulk-forming laxatives as ordered
    C) Performing deep palpation as ordered to promote peristalsis
    D) Preparing the patient for surgical bowel resection

Answer 57

D) Preparing the patient for surgical bowel resection