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CNCM 418 > MIDTERM > Flashcards

MIDTERM Flashcards

1
Q

A 62-year-old male with a history of coronary artery disease presents to the emergency department with substernal, squeezing chest tightness of 2 hour-duration. The patient appears anxious and restless. Which observation by the nurse helps to determine that the client’s pain is due to Myocardial Infarction?

A.
The patient experienced no nausea and vomiting.
B.
The client reports that the pain began while pushing a lawnmower.
C.
The pain, unrelieved by nitroglycerin and rest, is relieved with Morphine Sulfate.
D.
The pain is described as substernal and radiating to the left arm.

A

D.
The pain is described as substernal and radiating to the left arm.

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2
Q

Which of the following nursing actions is the priority of care for a client exhibiting signs of myocardial infarction?

Select one:
A.
Educate the client about his symptoms.

B.
Administer sublingual nitroglycerin.

C.
Decrease anxiety.

D.
Place patient on bed rest and peaceful environment.

A

C.
Decrease anxiety.

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3
Q

The nurse should be most concern about which of the following findings associated with chest pain?

A.
Pain is relieved with rest

B.
Pain is relieved with 1 nitroglycerin

C.
Pain lasts longer than 20 minutes

D.
Pain increases with inspiration

A

C.
Pain lasts longer than 20 minutes

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4
Q

Which of the following correctly characterizes the clinical presentation of myocardial infarction?

Select one:
A.
Chest pain associated with myocardial infarction varies with movement, deep breathing, and/or body movement.

B.
All patients with myocardial infarction have chest pain.

C.
Chest pain may occur together with diaphoresis, nausea, vomiting, and shortness of breath.

D.
Chest pain is the sole diagnostic determinant of myocardial infarction.

A

C.
Chest pain may occur together with diaphoresis, nausea, vomiting, and shortness of breath.

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5
Q

Which of the following statements is TRUE regarding the difference between myocardial infarction and myocardial ischemia?

Select one:
A.
Ischemia is associated with myocardial cell necrosis, whereas infarction is not

B.
Ischemia is not reversible, whereas infarction is

C.
Ischemia follows infarction

D.
Infarction is not reversible, whereas ischemia is

A

D.
Infarction is not reversible, whereas ischemia is

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6
Q

The cardinal sign of acute myocardial infarction is which of the following?

a. Substernal chest pain unrelieved by rest
b. Pain in the shoulder and left arm
c. Pain relieved by nitroglycerin
d. Shortness of breath

A

a. Substernal chest pain unrelieved by rest

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7
Q

Elderly patients are prone to increased complications related to tissue perfusion following myocardial infarction because:

a. Peripheral vascular resistance decrease with aging
b. Blood is hypercoagulable and clots more quickly
c. Peripheral vascular resistance increases with aging
d. Cardiac medications are less effective for this population

A

c. Peripheral vascular resistance increases with aging

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8
Q

Which of the following procedures must the nurse prioritize to carry out within 10 minutes upon admission of the patient presenting with chest discomfort?

a. Arterial blood gas (ABG)
b. Echocardiogram (2DEcho)
c. Cardiac enzyme (Biomarkers)
d. Electrocardiogram (12-Lead ECG)

A

d. Electrocardiogram (12-Lead ECG)

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9
Q

Elevated ST segments during the late phase of an acute myocardial infarction are indicative of which of the following?

a. Necrosis
b. Injury
c. Reperfusion
d. Ischemia

A

b. Injury

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10
Q

The nurse understands that abnormal Q waves develop on the EKG following acute myocardial infarction because:

a. Reduce blood flow leads to reduced cardiac output
b. They indicate that the patient needs a pacemaker
c. Speed of impulse conduction is facilitated by infarction
d. Necrotic tissue cannot conduct electrical current

A

d. Necrotic tissue cannot conduct electrical current

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11
Q

The ICU nurse performed 12-Lead ECG and interpreted the ECG strips as shown below:
The nurse understands that the patient needs rapid assessment and immediate intervention because the infarcted area in two contiguous leads is located in the:

a. Posterior wall
b. Lateral wall
c. Inferior wall
d. Anterior wall

A

d. Anterior wall

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12
Q

A 49-year-old white woman was admitted with an acute ST-segment elevation myocardial infarction. The nurse is aware that fibrinolytic therapy should be administered 30 minutes post-symptom onset (door-to-needle time). Which is the priority nursing assessment before the fibrinolytic therapy?

a. The duration of chest pain
b. The associated symptoms of MI
c. Time of onset of current chest pain
d. Character of chest pain

A

c. Time of onset of current chest pain

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13
Q

The rationale for administering a thrombolytic agent is which of the following?

a. To restore blood flow through an artery via lysis of the clot
b. Anticoagulant to prevent formation of new clots
c. Dilation of blocked arterial vessel which restores flow
d. To dissolve atherosclerotic plaque at the site of the blockage

A

a. To restore blood flow through an artery via lysis of the clot

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14
Q

The client diagnosed with acute ST-segment elevation myocardial infarction will receive tissue plasminogen activator (t-PA) administration. As part of the nursing responsibility prior to fibrinolytic therapy the nurse should know the following contraindications. SELECT ALL THAT APPLY:
1. Previous intracranial hemorrhage ischemic stroke within 3 months
2. Active bleeding or bleeding disorders
3. Significant closed head and facial trauma within 3 months
4. Suspected aortic dissection

a. 2, 3, 4
b. 1, 2, 4
c. 1, 2, 3, 4
d. 1, 2, 3

A

c. 1, 2, 3, 4

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15
Q

During the recovery phase following acute myocardial infarction, Aspirin 162 mg per orem is prescribed daily for what purpose?

a. To reduce the serum cholesterol level
b. For treatment of nitroglycerin-induced headache
c. To prevent and reduce blood clots
d. To decrease oxygen demand

A

c. To prevent and reduce blood clots

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16
Q

The nurse knows that the patient understands the rationale for administering low-dose aspirin following acute myocardial infarction when the patient makes which of the following statements?

a. “Aspirin will keep my fever down.”
b. “Aspirin will help me sleep at night.”
c. “Aspirin will helps manage my pain.”
d. “Aspirin keeps my platelets from clumping.”

A

d. “Aspirin keeps my platelets from clumping.”

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17
Q
  1. A 50-year-old male client is hospitalized for an acute anterior transmural myocardial infarction with 60% damage of the ventricular wall. Which of the following conditions resulting to crackles on both lung fields upon auscultation?

a. Pulmonic valve malfunction
b. Left-sided heart failure
c. Tricuspid valve malfunction
d. Right-sided heart failure

A

b. Left-sided heart failure

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18
Q

The nurse expects which of the following ECG changes in the patient who is experiencing myocardial ischemia?

a. Depressed PR interval
b. Elevated PR interval
c. Prolong QT interval
d. ST segment depression

A

d. ST segment depression

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19
Q

A 55-year old client is admitted with chest pain that radiates to the neck, jaw, and shoulders that occurs at rest. He also presents with high body temperature, weak with generalized sweating and decrease blood pressure. Cardiac biomarkers were ordered after the ECG procedure. Which of the following blood test is highly specific to cardiac tissue and most reliable to confirm myocardial infarction?

a. Myoglobin
b. Lactate dehydrogenase (LDH)
c. Troponin I
d. Creatinine kinase (CK-MB)

A

c. Troponin I

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20
Q

An emergency nurse assessed a patient with acute chest pain accompanied by shortness of breath and diaphoresis. The nurse documented that the onset of the pain was only two hours ago. Which of the following cardiac enzymes test is most sensitive early marker for accurate diagnosis?

a. Lactate dehydrogenase (LDH)
b. Creatinine kinase (CK-MB)
c. Troponin I
d. Myoglobin

A

d. Myoglobin

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21
Q

The physician orders continue intravenous Nitroglycerin infusion for the client with a suspected myocardial infarction. The most important nursing interventions when administering this drug is to:

a. Monitor urine output hourly.
b. Observe for adverse reaction.
c. Monitor blood pressure every 15 minutes.
d. Obtaining serum potassium level daily.

A

c. Monitor blood pressure every 15 minutes.

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22
Q

A nurse will administer Morphine Sulfate 2mg IV push as ordered. It is the drug of choice associated with acute MI to:

a. relieve the client’s pain
b. sedate the client
c. decrease the client’s anxiety
d. decrease the oxygen demand

A

a. relieve the client’s pain

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23
Q

When caring for the patient who has received thrombolytic therapy, the nurse will assess for which for the following side effects?

a. Bruising at access sites
b. Bradycardia
c. Disorientation
d. Dysrhythmias

A

a. Bruising at access sites

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24
Q

A coronary care unit nurse is caring for a client admitted with acute myocardial infarction. The nurse monitors for which most frequent complication of myocardial infarction:

a. Respiratory failure
b. Cardiogenic shock
c. Congestive heart failure
d. Cardiac dysrhythmias

A

c. Congestive heart failure

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25
Q

The nurse is caring for a patient admitted from the emergency department with the diagnosis “rule out myocardial infarction.” The patient’s chest pain recurred after 1 hour. Which of the following findings would be most significant in light of the diagnosis?

a. The pain improves when the patient sits upright in bed
b. The pain is described as pressure or aching in the right chest
c. The pain is accompanied by ST-segment elevation on leads V3 and V4
d. The pain is relieved following two nitroglycerin tablets

A

c. The pain is accompanied by ST-segment elevation on leads V3 and V4

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26
Q

A client manifested fatigue, hypotension, bradycardia, thready pulse which are the typical signs of decreased cardiac output. Which of the following is a compensatory response initiated by the sympathetic nervous system?

a. Increased heart rate and blood pressure
b. Alteration in level of consciousness
c. Decrease blood pressure
d. Decreased blood pressure and diuresis

A

a. Increased heart rate and blood pressure

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27
Q

Which of the following diagnostic test is most commonly used to determine the blockage in the artery and its severity (stenosis) through catheterization?

a. Coronary angiogram
b. Echocardiogram (2D-Echo)
c. Electrocardiogram (ECG)
d. Cardiac enzymes (Biomarkers)

A

a. Coronary angiogram

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28
Q

A client who recently diagnosed with myocardial infarction is scheduled to have Percutaneous Transluminal Coronary Angioplasty (PTCA) or Percutaneous Coronary Intervention (PCI). The nurse plans to teach the client that during this procedure a balloon-tipped catheter will:

a. Push the plaque to the distal area of the coronary artery
b. Be positioned in a coronary artery to take pressure measurement in the vessel
c. Be used to compress the plaque against the endothelium of the coronary artery
d. Cut away the plaque from the coronary artery wall using a cutting blade

A

a. Push the plaque to the distal area of the coronary artery

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29
Q

Which of the following are true about coronary artery bypass graft (CABG)? SELECT ALL THAT APPLY:
1. Bypass a blockage area of artery
2. Requires median sternotomy or open heart procedure
3. Artery or vein used for bypass is connected to inferior or superior vena cava
4. Also known as revascularization

a. 1, 2, 3
b. 1, 3, 4
c. 1, 2
d. 1, 2, 4

A

d. 1, 2, 4

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30
Q

The Emergency Room nurse was doing a comprehensive interview with regards to the risk factors of a Heart Failure. Which of the following list of risk factors predisposes a client for heart failure? SELECT ALL THAT APPLY:
1. Cigarette smoking
2. Controlled Hypertension
3. Obesity
4. Diabetes
5. Heart valve disease (E.g. aortic stenosis)
6. Cardiomyopathy (heart muscle disease)

a. 3, 4, 5, 6
b. 1,2,3,4,5,6
c. 2,3,4,5,6
d. 1,3,4,5,6

A

d. 1,3,4,5,6

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31
Q

Which of the following medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?

a. Digoxin
b. Losartan
c. Furosemide
d. Metoprolol

A

a. Digoxin

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32
Q

During initial assessment of a patient with suspected right-sided heart failure, which of the following findings should alert the nurse to monitor the patient closely?

a. Distended neck vein with HOB elevated
b. Respiratory rate of 22 breaths per minute
c. Capillary refill of less than 3 seconds
d. Blood pressure of 142/88 while standing

A

a. Distended neck vein with HOB elevated

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33
Q

The nurse is performing an assessment on a client with left-sided heart failure. The following are signs and symptoms of this disorder. SELECT ALL THAT APPLY:
1. Increased pulmonary artery pressure (PAP)
2. Bibasilar crackles
3. Dyspnea
4. Distended jugular vein
5. Frothy sputum

a. 1, 2, 3, 5
b. 1, 2, 3, 4
c. 1, 3, 4, 5
d. 2, 3, 4, 5

A

a. 1, 2, 3, 5

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34
Q

Digoxin (Lanoxin) is the drug of choice for treatment of patients with heart failure in which of the following circumstances?

a. To control heart rate and increase contractility
b. To sustain high cardiac output states
c. To reduce myocardial oxygen consumption
d. To produce a positive chronotropic effect

A

a. To control heart rate and increase contractility

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35
Q

A patient has been placed on Digoxin to treat heart failure. The nurse monitors the patient for signs and symptoms of possible Digoxin toxicity which includes. SELECT ALL THAT APPLY:
1. Nausea
2. Vomiting
3. Yellowish green halos
4. Bleeding

a. 1,2,3,4
b. 2,3,4
c. 1,3,4
d. 1,2,3

A

d. 1,2,3

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36
Q

In assessing a patient who receives treatment with digoxin (Lanoxin), the nurse must anticipate the cues of digoxin toxicity. Which of the following are most common early indicators of digoxin toxicity?

a. Nausea and vomiting
b. Visual disturbance and headache
c. Abdominal discomfort and weakness
d. Ventricular tachycardia and confusion

A

a. Nausea and vomiting

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37
Q

The patient manifested signs of Digoxin toxicity after 24 hours of taking the medications. The nurse referred immediately the assessment findings to the doctor on duty. Which of the following antidotes should the nurse prepare to relieve the patient from the toxicity?

a. Protamine Sulfate
b. Sodium Bicarbonate
c. Digibind or DigiFab
d. Glucagon

A

c. Digibind or DigiFab

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38
Q

Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?

a. Risk for infection related to stasis of alveolar secretions.
b. Constipation related to immobility.
c. Impaired skin integrity related to pressure.
d. Activity intolerance related to pump failure.

A

d. Activity intolerance related to pump failure.

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39
Q

Acute pulmonary edema caused by heart failure is usually a result of infarct to which of the following area of the heart?

a. Right ventricle
b. Left atrium
c. Left ventricle
d. Right atrium

A

c. Left ventricle

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40
Q

Which of the following positions would best aid breathing for a client with acute pulmonary edema?

a. Trendelenburg’s position
b. High-fowler’s position
c. Lying flat in bed
d. Left-sided lying

A

b. High-fowler’s position

41
Q

The nurse assessed a client diagnosed with right-sided heart failure. The following findings are the manifestation of this disorder. SELECT ALL THAT APPLY:
1. Splenomegaly
2. Hepatomegaly
3. Pulmonary edema
4. Edema on lower extremities
5. Distended jugular vein
6. Ascites

a. 1, 2, 3, 4, 6
b. 1, 3, 4, 5, 6
c. 1, 2, 4, 5, 6
d. 1, 2, 3, 4, 5

A

c. 1, 2, 4, 5, 6

42
Q

In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client:

a. Renal failure
b. Diabetes
c. Right-sided heart failure
d. Pulmonary emboli

A

c. Right-sided heart failure

43
Q

A patient with heart failure is being prepared for discharge from the hospital. Furosemide (Lasix) 20 mg tablet has been ordered daily. What the nurse should teach the patient at home to assess the effectiveness of this therapy?
a. Drink at least 2000 ml daily
b. Check blood pressure daily
c. Plan a low sodium diet
d. Check weight daily

A

b. Check blood pressure daily

44
Q

Drugs like nitroglycerin and isosorbide dinitrate (Isordil) provide effective treatment for patients with heart failure because they work by which of the following mechanism?

a. Decrease preload and afterload of the heart muscle
b. Inhibit the effects of the sympathetic nervous system
c. Suppress the renin-angiotensin-aldosterone system
d. Reduce left ventricular workload

A

a. Decrease preload and afterload of the heart muscle

45
Q

The nurse who is preparing to administer digoxin (Lanoxin) discovers that the patient, who previously had a regular heart rate, now has an irregular heart rate of 48. Which of the following actions by the nurse represents best practice?

a. The nurse reassess the apical heart for a full minute
b. The nurse assesses for signs of hypovolemia
c. The nurse administers the dose to regulate the heart rate
d. The nurse withholds the ordered dose of medication

A

d. The nurse withholds the ordered dose of medication

46
Q

A nurse performs an assessment on a client with acute pulmonary edema and notes the following findings: severe dyspnea, RR- 34 breaths per minute, and diffuse crackles on lung auscultation. Arterial Blood Gas (ABG) test followed. Which of the following ABG results best fit the findings stated above?

a. Metabolic alkalosis
b. Respiratory acidosis
c. Respiratory alkalosis
d. Metabolic acidosis

A

b. Respiratory acidosis

47
Q
  1. Which clinical manifestations of respiratory failure does an acidotic patient experiences?

a. Hyperventilation with hypoxemia
b. Hypoventilation with hypoxia
c. Hypoventilation with dizziness and seizures
d. Hyperventilation with hypoxia and disorientation

A

d. Hyperventilation with hypoxia and disorientation

48
Q

A client’s Arterial Blood Gas report is as follows: pH: 7.35, pO2: 85, pCO2: 55, HCO3: 25. The nurse interprets these values as:
a. Compensated respiratory acidosis
b. Uncompensated respiratory acidosis
c. Compensated metabolic acidosis
d. Uncompensated metabolic acidosis

A

a. Compensated respiratory acidosis

49
Q

A diagnostic finding of patient’s arterial blood gas (ABG) is as follows: pH: 7.25mmHg, pCO2: 57mmHg, HCO3: 16mEq/L. Which of the following is the correct ABG reading for this result?

a. Mixed acidosis
b. Fully compensated respiratory alkalosis
c. Uncompensated metabolic acidosis
d. Partially compensated metabolic acidosis

A

a. Mixed acidosis

50
Q

After admitting a client with Coronary Artery Disease, the nurse formulates a nursing diagnosis of Decreased Cardiac Output related to possible dysrhythmia as evidenced by irregular heartbeat, dyspnea and syncopal episode. The nurse should plan for which action in the care of the client?

a. Measure the client’s blood pressure every four hours
b. Monitor oxygen saturation levels every four hours
c. Check capillary levels every four hours
d. Attach the client on a cardiac monitor

A

d. Attach the client on a cardiac monitor

51
Q

A child was found unconscious at home and brought to the emergency department by the fire and rescue unit. Physical examination showed cherry-red mucous membranes, nail beds, and skin. The nurse suspects the child’s condition was the result of which of the following?

a. Hydrocarbon ingestion
b. Organophosphate ingestion
c. Aspirin ingestion
d. Carbon monoxide poisoning

A

d. Carbon monoxide poisoning

52
Q

A child has ingested a poisonous substance. What is the priority intervention?

a. Give 1 liter of water
b. Perform Cardio-Pulmonary Resuscitation
c. Make the child vomit
d. Empty the mouth of pills or other materials

A

d. Empty the mouth of pills or other materials

53
Q

The nurse is caring for a child in the recovery phase following an ingestion of drain cleaner. The nurse is aware that the child is at risk for which of the following?

a. Esophageal strictures
b. Esophageal varices
c. Tracheal varices
d. Tracheal strictures

A

a. Esophageal strictures

54
Q

Initially, in a patient with suspected carbon monoxide poisoning, the most important intervention at the scene of poisoning is:

a. Administer oxygen and loosen the client’s clothing
b. Carry the client on the fresh air immediately; open all windows and doors if the area is enclosed
c. Conduct a head-to-toe physical assessment
d. Assess the patient’s airway breathing and circulation

A

b. Carry the client on the fresh air immediately; open all windows and doors if the area is enclosed

55
Q

Which of the following laboratory results is constantly checked in clients undergoing treatment for carbon monoxide poisoning?

a. Skin color
b. Carboxyhemoglobin level
c. Oxygen saturation
d. RBC count

A

b. Carboxyhemoglobin level

56
Q

What is the antidote for respiratory depression caused by Opioids?

a. Pralidoxime
b. Naloxone (Narcan)
c. Acetylcysteine
d. Oxygen

A

b. Naloxone (Narcan)

57
Q

What is the antidote for Acetaminophen toxicity?

a. Pralidoxime
b. Acetylcysteine
c. Naloxone
d. Amyl nitrite

A

b. Acetylcysteine

58
Q

What is the antidote for Organophosphate poisoning?

a. Acetylcysteine
b. Amyl nitrite
c. Pralidoxime
d. Naloxone

A

c. Pralidoxime

59
Q

Which of the following is NOT part of the criteria for Acute Kidney Injury (AKI) as defined by Acute Kidney Injury Network?
a. An absolute increase in the serum creatinine level of more than or equal to 0.3mg/dL
b. A reduction in urine output (documented oliguria of less than 0.5 mL/kg/hr for more than 6 hours
c. A percentage increase in serum creatinine of more than or equal to 50%
d. A percentage increase in blood urea nitrogen level of more than or equal to 50%

A

d. A percentage increase in blood urea nitrogen level of more than or equal to 50%

60
Q

A 55-year-old male patient is admitted with a massive GI bleed. The patient is at risk for what type of acute kidney injury?

a. Intrinsic renal
b. Post-renal
c. Intra-renal
d. Pre-renal

A

d. Pre-renal

61
Q

A client with Acute Kidney Injury has an increase in the serum potassium level. The nurse should monitor the client for:

a. Pulmonary edema
b. Arrhythmia
c. Circulatory collapse
d. Hemorrhage

A

b. Arrhythmia

62
Q

Which abnormal blood value would not be improved by dialysis treatment?

a. Decreased hemoglobin concentration
b. Hyperkalemia
c. Hypernatremia
d. Elevated serum creatinine level

A

a. Decreased hemoglobin concentration

63
Q

Patients with Acute Kidney Injury are most at risk of which acid-base imbalance?
a. Respiratory Acidosis
b. Metabolic Alkalosis
c. Respiratory Alkalosis
d. Metabolic Acidosis

A

d. Metabolic Acidosis

64
Q

A client developed cardiogenic shock after a severe myocardial infarction and has now developed Acute Kidney Injury. The client’s family asks the nurse why the client has developed Acute Kidney Failure. The nurse should base the response on the knowledge that there was:

a. Structural damage to the kidney resulting in acute tubular necrosis
b. An obstruction of urine flow from the kidneys
c. A decrease in the blood flow through the kidneys
d. A blood clot formed in the kidneys

A

c. A decrease in the blood flow through the kidneys

65
Q

Which of the following electrolyte imbalances is usually evident in a patient with Acute Kidney Injury?

a. Hypocalcemia
b. Hypochloremia
c. Hypokalemia
d. Hypophosphatemia

A

a. Hypocalcemia

66
Q

A nurse is developing a nursing care plan for a patient in the diuresis stage of AKI. What nursing diagnosis would be included in the care plan?

a. Urinary retention
b. Acute pain
c. Risk for electrolyte imbalance
d. Excess fluid volume

A

c. Risk for electrolyte imbalance

67
Q

A patient with AKI has a urinary output of 350 mL/day. In addition, morning labs showed an increased BUN and creatinine level along with potassium level of 6 mEq/L. What type of diet ordered by the physician is most appropriate for this patient?

a. High protein, high sodium, high potassium
b. High protein, low sodium, high potassium
c. Low protein, low sodium, low potassium
d. High protein, high sodium, low potassium

A

c. Low protein, low sodium, low potassium

68
Q

In the trimodal distribution of trauma deaths, the “golden hour” for the critically injured is under the:
a. Fourth peak
b. First peak
c. Third peak
d. Second peak

A

d. Second peak

69
Q

An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do FIRST?

a. Determine the identity of the client
b. Establish an airway
c. Check for fractures
d. Stop bleeding from open wounds

A

b. Establish an airway

70
Q

In conducting a primary survey on a trauma patient, which of the following is considered one of the PRIORITY elements?

a. Palpation and auscultation of the abdomen
b. Brief neurologic assessment
c. Complete set of vital signs
d. History taking

A

b. Brief neurologic assessment

71
Q

A nurse is caring for a head injury patient with a GCS of 10. This Traumatic Brain Injury is classified as:

a. Chronic
b. Moderate
c. Mild
d. Severe

A

b. Moderate

72
Q

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which nursing intervention should be done FIRST?

a. Notify the physician of potential cerebrospinal fluid leak
b. Position the client flat in bed
c. Suction the nose to maintain airway patency
d. Insert nasal and ear packing with sterile gauze

A

a. Notify the physician of potential cerebrospinal fluid leak

73
Q

The “Battle sign” in a patient with head trauma MOST LIKELY indicates a:

a. Basilar skull fracture
b. Contusion
c. Vault skull fracture
d. Cerebral hematoma

A

a. Basilar skull fracture

74
Q

Middle meningeal artery laceration causes collection of arterial blood between the inner skull and the outermost dura. This is referred to as:

a. Intracerebral hematoma
b. Epidural hematoma
c. Diffuse axonal injury
d. Subdural hematoma

A

b. Epidural hematoma

75
Q

A 75-year-old man is admitted for transient ischemic attack with left-sided weakness. During the admission assessment, the patient states he is also experiencing absentmindedness, vomiting, and intermittent photophobia. The patient is on warfarin (Coumadin) therapy. The patient cannot recall any significant injury involving a blow to his head. Based on this information, what is the MOST LIKELY cause of his symptoms?

a. Subacute subdural hematoma
b. Epidural hematoma
c. Acute subdural hematoma
d. Chronic subdural hematoma

A

d. Chronic subdural hematoma

76
Q

A 75-year-old man is admitted for transient ischemic attack with left-sided weakness. During the admission assessment, the patient states he is also experiencing absentmindedness, vomiting, and intermittent photophobia. The patient is on warfarin (Coumadin) therapy. The patient cannot recall any significant injury involving a blow to his head. Based on this information, what is the MOST LIKELY cause of his symptoms?

a. Subacute subdural hematoma
b. Epidural hematoma
c. Acute subdural hematoma
d. Chronic subdural hematoma

A

d. Chronic subdural hematoma

77
Q

A patient is admitted for an injury of C5 and C6 after a motor vehicular crash (MVC) with head-on collision. The type of injury that the nurse can expect to see with this Spinal Cord Injury is:

a. Rotation
b. Hyperflexion
c. Axial loading
d. Hyperextension

A

b. Hyperflexion

78
Q

A spinal cord-injured patient is complaining of loss of motor function and loss of sensations of pain and temperature below the level of injury. The nurse suspects that this patient’s injury is:

a. Brown-Sequard Syndrome
b. Anterior Cord Syndrome
c. Posterior Cord Syndrome
d. Central Cord Syndrome

A

b. Anterior Cord Syndrome

79
Q
  1. A nurse assesses a client who has episodes of autonomic dysreflexia. Which condition can cause this?

a. Lumbar spinal cord injury
b. Traumatic Brain Injury
c. Hypovolemia
d. Full bladder

A

d. Full bladder

80
Q

A client is experiencing an episode of autonomic dysreflexia and becomes hypertensive. The MOST IMPORTANT intervention by the nurse would be:

a. Elevate the client’s legs
b. Place the bed in Trendelenburg’s position
c. Place the client flat on bed
d. Place the client in high Fowler’s position

A

d. Place the client in high Fowler’s position

81
Q

Client teaching for a client with Gardner-Wells tongs should include which reason for their use?

a. To prevent the need for surgery
b. To reduce intracranial pressure
c. To stabilize the neck and reduce dislocations
d. To prevent deep vein thrombosis

A

c. To stabilize the neck and reduce dislocations

82
Q
  1. A patient came into the ER with maxillofacial skeleton fracture. The patient is almost unrecognizable because of craniofacial disruption. The injury is classified as:
    a. Le Fort II
    b. Le Fort III
    c. Le Fort IV
    d. Le Fort I
A

b. Le Fort III

83
Q

A nurse is caring for a patient with blunt chest trauma after a motor vehicle accident. The patient starts to complain of pain from the chest to the shoulder and a sense of impending doom. Upon assessing the patient, the nurse notes that the patient has diminished breath sounds on the left side, jugular vein distention, and tracheal deviation to the right. The nurse anticipates:

a. A chest radiograph
b. Insertion of an indwelling urinary catheter
c. Administration of pain medications
d. Insertion of a chest tube

A

d. Insertion of a chest tube

84
Q

A patient was brought to ER with an open sucking chest wound. Which of the following will be your PRIORITY intervention?

a. Insert a large bore needle to remove air
b. Insert a chest-tube to decrease pressure inside the lungs
c. Close the wound at end expiration with sterile occlusive dressing
d. Bring immediately to the OR for a STAT surgical repair

A

c. Close the wound at end expiration with sterile occlusive dressing

85
Q

Which of the following is NOT part of Beck’s triad?
a. Muffled heart sounds
b. Neck vein distention
c. Elevated Central Venous Pressure
d. Hypertension

A

d. Hypertension

86
Q

Ecchymosis in the flank area usually due to retroperitoneal bleeding or pancreatic injury is known as:
a. Cullen sign
b. Rovsing’s sign
c. McBurney’s sign
86. Ecchymosis in the flank area usually due to retroperitoneal bleeding or pancreatic injury is known as:
a. Cullen sign
b. Rovsing’s sign
c. McBurney’s sign
d. Turner-Grey sign

A

d. Turner-Grey sign

87
Q

A patient with blunt trauma to the upper abdomen has a positive Kehr sign. Kehr sign in this trauma patient MOST LIKELY indicates a:
a. Ruptured bladder
b. Ruptured diaphragm
c. Ruptured kidney
d. Ruptured spleen

A

d. Ruptured spleen

88
Q

The PRIORITY nursing diagnosis for the patient in shock regardless of the phase or type is:

a. Imbalanced Nutrition: less than body requirements
b. Ineffective breathing pattern
c. Ineffective tissue perfusion
d. Deficient fluid volume

A

c. Ineffective tissue perfusion

89
Q

Shock can be classified based on the etiology. Shock can be a result of loss of circulating volume; of the impaired ability of the heart to pump; or from maldistribution of circulating blood volume, also known as distributive shock. Which of the following does NOT belong in the distributive type of shock?

a. Cardiogenic shock
b. Neurogenic Shock
c. Anaphylactic Shock
d. Septic Shock

A

a. Cardiogenic shock

90
Q

A postoperative patient has a heart rate of 110 beats/min and blood pressure (BP) of 110/80 mm Hg (previously 130/60 mm Hg). Urine output has been 20 mL/hr for the past 3 hours, capillary filling time is 5 seconds, the skin is cool, the neck veins are flattened, and the patient is complaining of thirst. The nurse suspects that:

a. The patient has a cardiac tamponade
b. The patient is having an allergic reaction
c. The patient is in cardiogenic shock
d. The patient is experiencing hypovolemic shock

A

d. The patient is experiencing hypovolemic shock

91
Q

Which of the following is an absolute cause of hypovolemic shock

a. Increased capillary permeability
b. Decreased colloidal osmotic pressure
c. Loss of whole blood
d. Vasodilation

A

c. Loss of whole blood

92
Q

A client is admitted with manifestations of confusion, decreased blood pressure, increased heart rate and cold clammy skin with marked delayed capillary refill. The estimated fluid volume loss is about 1800 mL. This hypovolemic shock is classified as:
a. Class I
b. Class III
c. Class II
d. Class IV

A

b. Class III

93
Q

The nurse in the cardiac unit is reviewing the conditions of the assigned clients to determine if a risk of cardiogenic shock is present. The client MOST at risk presents with which condition?
a. Decreased hemoglobin level
b. Hypotension
c. Acute myocardial infarction
d. Coronary artery disease

A

c. Acute myocardial infarction

94
Q

The nurse is planning care for a client in cardiogenic shock. What is the PRIORITY goal?
a. Correct hypoxia
b. Prevent infarction
c. Correct metabolic acidosis
d. Increase myocardial oxygen supply

A

d. Increase myocardial oxygen supply

95
Q

A patient is having a sudden and severe anaphylactic reaction to a medication. The nurse immediately stopped the medication and called a rapid response. The patient’s blood pressure is 80/50, heart rate is 120, and oxygen saturation is 86%. Audible wheezing is noted along with facial redness and swelling. The nurse knows that the first-line treatment for this condition is?
a. Beta-adrenergic Agents
b. Epinephrine
c. Diphenhydramine
d. Corticosteroids

A

b. Epinephrine

96
Q

A nurse is providing care to a patient in anaphylactic shock. Which of the following is NOT a typical treatment for this condition, and if ordered, warrants clarification by the nurse?
a. IV Furosemide
b. IM Epinephrine
c. Corticosteroids
d. Isotonic intravenous fluids

A

a. IV Furosemide

97
Q

The most common etiology of Neurogenic Shock is:

a. Spinal Cord Injury
b. Cerebrovascular Accident
c. Traumatic Brain Injury
d. Subdural Hematoma

A

a. Spinal Cord Injury

98
Q

A patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in the patient would indicate that the medication is working?
a. Blood pH of 7.19
b. Mean arterial pressure (MAP) of 90 mmHg
c. Decreased central venous pressure
d. Blood pressure of 70/40

A

b. Mean arterial pressure (MAP) of 90 mmHg

99
Q

A nurse is providing care to four patients. SELECT ALL the patients who are at risk for developing sepsis:
1. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place.
2. A 55-year-old male who is a recent kidney transplant recipient.
3. A 78-year-old female with diabetes mellitus who is recovering from colon surgery.
4. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

a. 1,3,4
b. 1,2,3,4
c. 1,2
d. 1,2,3

A

b. 1,2,3,4

CNCM 418 (5 decks)

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