Unit 2: Messer Practice Questions Flashcards by Mary Price

An alert and oriented patient is admitted to ED with a GCS of 10. Which finding should the nurse report to physician immediately?
A. Photophobia with Headache
B. New Onset of Dizziness
C. Brisk Pupil Response
D. Sudden Drowsiness

D. Sudden Drowsiness

ICP!!

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The nurse is caring for a patient with a TBI who is NPO and sedated on a ventilator. The nurse notices drainage on the pillowcase displaying a positive halo sign. What is the priority concern for this patient?
A. Inability to communicate
B. Nutritional deficit
C. Risk for acquiring infection
D. Risk for Ventilator-Associated Pneumonia

C. Risk for acquiring infection

Halo Sign = CSF leak
- most likely due to a Basilar skull fracture

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A patient with Myasthenia gravis has flaccid paralysis. A tensilon challenge is performed. Discuss potential results, interpret results, and any complications (and subsequent interventions)

Paralysis improves → Myasthenia crisis
- Protect airway → O2, possibly intubate or BIPAP
- Plasmaphoresis
Paralysis worsens → Cholinergic crisis
- Manage airway → Thick secretions
- Give atropine

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Discuss priority assessment (and interventions) for a patient with a C2-C3 SCI

ABC’s
Preventing a secondary injury (spinal precautions)
Neuro assessments
Getting as much information as possible

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A patient is in MG cholinergic crisis. What are your concerns and likely interventions?

Respiratory issues- breathing issues-
Suctioning
Atropine
Later- nutrition, speech

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Discuss Education to help a person with a SCI and subsequent paralysis to prevent pneumonia

Cough
Deep breathing
IS
Preventing aspiration PNA
Ineffective cough? Assisted cough
P & V

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What are the early manifestations of MS?

Visual issues
Sensory issues
Mobility issues

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Discuss early and late manifestations of ALS

Early → Fatigue, weakness, upper arms → facial weakness

Late →Complete paralysis and respiratory decline

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What are the criteria for organ donation? (4)

Coma for known cause
Normal body temperature
Normal blood pressure > 100
Neuro exam- 2 providers

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What are the indicators of a poor prognosis for a TBI?

Hypoxia
Fever **
Blown or fixed pupils
Low CPP <70
2 point change in GCS (important indicator of changes/ decline)
Cushing’s triad (bad sign) = herniation

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How do you calculate the CPP? What is this? What do the results mean?

MAP (> 65) – ICP (10-15)

MAP = [2 x (Diastolic) + Systolic]/3
Therapeutic CPP = 70 or greater
Brain perfusion – results <70 is an indicator of a poor prognosis, brain isn’t getting enough oxygen

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Discuss Cushing’s Triad. What does it look like, what does It mean and what should you do if it happens?

Cushing Triad = Increased ICP (late sign) → May very well be death
1. Widened pulse pressure (HTN)
2. Bradycardia
3. Changes in respirations (pattern)

Get help!
Code cart
Mannitol
Craniotomy

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A patient with an SCI (long-standing) tells you she thinks something bad is happening. You take VS’s: BP 210/111, HR 51. Discuss what you do first, second…

Autonomic Dysreflexia!!
1. Place pt in sitting position
2. Assess for cause
3.Get help
4. Nicardipine drip

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What are nursing interventions for a patient with increased ICP

Frequent neuro checks
HOB at 30-45 degrees
Diuretics (medical)
Strict I&Os
Suppress cough, Avoid constipation

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What are the causes of secondary TBI?

Ischemia, Inflammation
Excitatory stuff
Bleeding
Hypovolemia/Hypotension (MAP)
Neurogenic Shock
Hypoxia (PaO2 < 80)
Cerebral edema
Immobilization didn’t happen (no spinal board used)

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How do you prevent Secondary TBI?

Maintain CPP > 70 and MAP > 65
Monitor for Increased ICP (changes in LOC, HA) and GCS changes

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Presentation of Subdural hematoma vs Epidural bleed

epidural – LOC, awake, rapid decline
Subdural – can happen over hours to months

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What do you need to have at the bedside before administering tensilon for flaccid paralysis?

Atropine! If the issue isn’t r/t MG, then increasing Acth will cause a Cholinergic crisis

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Priority of care for a patient in myasthenia crisis

Sx Management!
Drug therapy: Cholinesterase inhibitor (Pyridostigmine) WITH food, Corticosteroids, IV IgG, and Monoclonal Abys
Plasmapheresis
Activity-rest balance (weakness worsens with activity)
Respiratory Mx: Assisted cough, suction, Chest physiotherapy, NPPV

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Education for a patient with MS

Potential for relapses
medication adherence
Avoid large crowds (immunosuppression)
Avoiding stress, ensuring rest
No strenuous Exercise to avoid Hyperthermia

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Priorities of care for a patient with GBS? Also, discuss the presentation of GBS (early signs and potential complications)

Ascending paralysis (peaks around 4 weeks)
Airway management

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Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and respirations of 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be ofmostconcern to the nurse?
A) BP of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min
B) BP of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min
C) BP of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min
D) BP of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min

A) BP of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min

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The nurse has administered the prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?
A) Blood pressure
B) Oxygen saturation
C) Intracranial pressure
D) Hemoglobin and hematocrit

C) Intracranial pressure

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An unconscious patient has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
A) Encourage coughing and deep breathing.
B) Position the patient with knees and hips flexed.
C) Keep the head of the bed elevated to 30 degrees.
D) Cluster nursing interventions to provide rest periods.

C) Keep the head of the bed elevated to 30 degrees.

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Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? A) Coordinate the transfer of the patient to the operating room. B) Provide discharge instructions about monitoring neurologic status. C) Transport the patient to radiology for magnetic resonance imaging (MRI). D) Arrange to admit the patient to the neurologic unit for 24 hours of observation.

B) Provide discharge instructions about monitoring neurologic status.

Which statement by patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? A) “I will return if I feel dizzy or nauseated.” B) “I am going to drive home and go to bed.” C) “I do not even remember being in an accident.” D) “I can take acetaminophen (Tylenol) for my headache.”

B) “I am going to drive home and go to bed.”

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? Document the BP and ICP in the patient’s record. Report the BP and ICP to the health care provider. Elevate the head of the patient’s bed to 60 degrees. Continue to monitor the patient’s vital signs and ICP.

Report the BP and ICP to the health care provider.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? Document the increase in intracranial pressure. Ensure that the patient’s neck is in neutral position. Notify the health care provider about the change in pressure. Increase the rate of the prescribed propofol (Diprivan) infusion.

Ensure that the patient’s neck is in neutral position.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? A 20-yr-old patient whose cranial x-ray shows a linear skull fracture A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 A 30-yr-old patient who lost consciousness for a few seconds after a fall A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? Pulse of 102 beats/min Temperature of 101.6° F Intracranial pressure of 15 mm Hg Mean arterial pressure of 90 mm Hg

Temperature of 101.6° F

A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after falling on the bathroom floor and losing consciousness. Which action will the nurse take first? Check oxygen saturation. Assess pupil reaction to light. Palpate the head for injuries Verify Glasgow Coma Scale (GCS) score

Check oxygen saturation.

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? The patient takes warfarin (Coumadin) daily. The patient’s blood pressure is 162/94 mm Hg. The patient is unable to remember the accident. The patient complains of a dull headache.

The patient takes warfarin (Coumadin) daily.

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

MAP = [2(76) + 130]/3 = 94 CPP = 94 - 20 = 74

The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about visual problems caused by ptosis. triggers leading to facial pain. poor appetite caused by loss of taste. weakness on the affected side of the face.

triggers leading to facial pain.

Which action will the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia? Assess fluid and dietary intake. Apply ice packs for 20 minutes. Teach facial relaxation techniques. Spend time talking with the patient.

Assess fluid and dietary intake.

Which assessment data for a patient with Guillain-Barré syndrome will require the nurse’s most immediate action? The patient’s sacral area skin is reddened. The patient is continuously drooling saliva. The patient complains of severe pain in the feet. The patient’s blood pressure (BP) is 150/82 mm Hg.

The patient is continuously drooling saliva.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? Involuntary and spastic movement Hypotension and warm extremities Hyperactive reflexes below the injury Lack of sensation or movement below the injury

Hypotension and warm extremities

The nurse will explain to the patient who has a T2 spinal cord transection injury that use of the shoulders will be limited. function of both arms should be retained. total loss of respiratory function may occur. tachycardia is common with this type of injury.

function of both arms should be retained.

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? Cardiac monitoring for bradycardia Assessment of respiratory rate and effort Administration of low-molecular-weight heparin Application of pneumatic compression devices to legs

Assessment of respiratory rate and effort

A patient who had a C7 spinal cord injury 1 month ago has a weak cough effort and crackles. The initial intervention by the nurse should be to suction the patient’s nasopharynx. notify the patient’s health care provider. push upward on the epigastric area as the patient coughs. suggest the patient receive a tracheostomy tube

push upward on the epigastric area as the patient coughs.

Which of these nursing actions for a patient with Guillain-Barré syndrome is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? Nasogastric tube feeding q4hr Artificial tear administration q2hr Assessment for bladder distention q2hr Passive range of motion to extremities q4h

Passive range of motion to extremities q4h

You are starting your shift in the emergency department, and you are assigned to work triage. Joe, a 43-year-old male comes in complaining of severe abdominal pain. What do you want to know about Joe?

OLD CARTS or OPQRST Pain characteristics + if radiating, aggravating factors, S/S r/t ABCs! Epigastric pain; radiates to his back Experiencing some Shortness of breath Pain worsens with activity Pain started when he was outside doing yard work It lasts for about 30-60 minutes after activity

Nursing priorities for Acute Pancreatitis

ABCs and Pain Mx with opiods

Nursing priorities for DKA

1. ABCs (protecting airway?) 2. VS (electrolyte imbalances) 3. Treat F&E imbalances (Severe dehydration, hyperglycemia, hyperkalemia)

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? “Do you have a history of IV drug use?” “Do you use any over-the-counter drugs?” “Have you used corticosteroids for any reason?” “Have you recently traveled to a foreign country?”

“Do you use any over-the-counter drugs?”

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? Hemoglobin Temperature Activity level Albumin level

Albumin level

Which topic is most important to include in patient teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? Taking lactulose Maintaining good nutrition Avoiding alcohol ingestion Using vitamin B supplements

Avoiding alcohol ingestion

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? Withhold both drugs. Administer both drugs Administer the furosemide. Administer the spironolactone

Administer the spironolactone

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? The patient is alert and oriented. The patient denies nausea or anorexia. The patient’s bilirubin level decreases. The patient has at least one stool daily.

The patient is alert and oriented.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? Instruct the patient to cough every hour. Monitor the patient’s respiratory status Verify the position of the balloon every 4 hours. Deflate the gastric balloon if the patient seems nausea

Monitor the patient’s respiratory status

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor bilirubin levels. ammonia levels. potassium levels. prothrombin time.

ammonia levels.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? Restrict daily dietary protein intake. Reposition the patient every 4 hours. Perform passive range of motion twice daily. Place the patient on a pressure-relief mattress

Place the patient on a pressure-relief mattress

Which finding indicates to the nurse that a patient’s transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? Increased serum albumin level Decreased indirect bilirubin level Improved alertness and orientation No episodes of bleeding varices

No episodes of bleeding varices

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? Calcium Bilirubin Amylase Potassium

Amylase

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? Nausea and vomiting Hypotonic bowel sounds Muscle twitching and finger numbness Upper abdominal tenderness and guarding

Muscle twitching and finger numbness

The nurse will ask a patient being admitted with acute pancreatitis specifically about a history of diabetes mellitus. high-protein diet. cigarette smoking. alcohol consumption.

alcohol consumption.

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) at bedtime. with meals. in the morning. for abdominal pain

with meals.

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) at bedtime. with meals. in the morning. for abdominal pain

with meals.

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective? The patient reports no chest pain. Blood pressure is 140/90 mm Hg. Stools test negative for occult blood. The apical pulse rate is 68 beats/minute.

Stools test negative for occult blood.

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient’s right hand. Which action should the nurse take next? Ask the patient about any arm pain. Retake the patient’s blood pressure. Check the calcium level in the chart. Notify the health care provider immediately.

Check the calcium level in the chart.

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? Bowel sounds are present. Grey Turner sign resolves. Electrolyte levels are normal. Abdominal pain is decreased.

Abdominal pain is decreased.

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain A 58-yr-old patient who has compensated cirrhosis and is complaining of anorexia A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain

A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient in: perform leg exercises hourly while awake. work with physical therapy. turn, cough, and deep breathe every 2 hours. choose preferred low-fat foods from the menu.

turn, cough, and deep breathe every 2 hours.