Cognition
Which level of brain injury is present in a patient with a Glasgow Coma Scale score ranging from 9 to 12?
A. Comatose brain injury
B. Mild traumatic brain injury
C. Severe traumatic brain injury
D. Moderate traumatic brain injury
D. Moderate Traumatic brain injury
Rationale
Patients with a Glasgow Coma Scale score ranging from 9 to 12 are categorized as having a moderate traumatic brain injury. A comatose patient or a patient with a severe brain injury would have a score of 8 or less on the Glasgow Coma Scale. A patient with a mild traumatic brain injury would have a score of 13 or higher.
Which device gives an accurate measurement of intracranial pressure (ICP)?
A. Subarachnoid bolt
B. Intraventricular catheter
C. Subdural/epidural catheter
D. Fiber optic transducer tipped catheter
B. Intraventricular catheter
Rationale
An intraventricular catheter is a monitoring device which allows accurate measurement of intracranial pressure (ICP). Subarachnoid bolts, subdural/epidural catheters, and fiber optic transducer tipped catheters are intracranial pressure monitoring devices, but they do not yield accurate measurement of intracranial pressure.
Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)?
A. Major burn
B. Minor burn
C. Severe burn
D. Moderate burn
D. Moderate Burn
Rationale
Deep partial-thickness burns affecting 15% to 25% TBSA are classified as moderate burns. Partial-thickness burns affecting more than 25% of TBSA are classified as major burns. Deep partial-thickness burns affecting less than 15% of TBSA are considered minor burns. Burns are categorized as three types: major, minor, and moderate. There is no "severe" burn category.
Which drug will be most effective for the treatment of cerebral edema and increased intracranial pressure?
A. Mannitol
B. Furosemide
C. Dexamethasone
D. Methylprednisolone sodium succinate
A. Mannitol
Rationale
Mannitol is an osmotic diuretic which helps in the treatment of cerebral edema. Furosemide is a loop diuretic, which is given with mannitol to increase its effectiveness. Dexamethasone and methylprednisolone sodium succinate are unassociated with the increased intracranial pressure treatment.
Mannitol
Which condition involves complete but temporary loss of motor, sensory, reflex, and autonomic function?
A. Spinal shock
B. Spinal tumor
C. Neurogenic shock
D. Penetrating trauma
A. Spinal Shock
Rationale
Spinal shock occurs when the cord immediately responds to the injury. Patients with spinal shock have complete but temporary loss of motor, sensory, reflex, and autonomic function. Spinal cord tumor causes ischemia and infarction. Neurogenic shock causes hypoperfusion due to severe cord injury. Penetrating trauma causes local damage to the spinal cord.
What is the priority assessment for a patient with bacterial meningitis?
A. Temperature
B. Blood pressure
C. Muscle function
D. Neurologic status
D. Neurologic status
Rationale
The most important thing to monitor in patients with meningitis is neurologic status. Blood pressure, temperature, and muscle function are important, but not as high a priority as neurologic assessment.
The nurse on a burn unit has just received a change-of-shift report about these patients. Which patient does the nurse assess first?
A. Adult patient admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain
B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"
C. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans
D. Older adult patient admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr
B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"
Rationale
Smoke inhalation and facial burns are associated with airway inflammation and obstruction; the patient with difficulty breathing needs immediate assessment and intervention. Although the patient admitted a week ago with deep partial-thickness burns is reporting pain, this patient does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the patient's condition does not warrant that the nurse should assess this patient first. The older adult patient admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.
Which drug is often used as adjunctive therapy to reduce the incidence of rebound from mannitol?
A. Propofol
B. Furosemide
C. Osmotic diuretic
D. Dexmedetomidine
B. Furosemide
Rationale
Furosemide, a loop diuretic, is often used as an adjunctive therapy to reduce the incidence of rebound from mannitol. Propofol and dexmedetomidine are sedative agents used as continuous infusions to manage agitation and ventilatory asynchrony. An osmotic diuretic is used to treat cerebral edema by pulling water out of the extracellular space of the edematous brain tissue.
A halo fixator with a jacket is used to immobilize the spine of a patient following a vertebral fracture. What nursing assessment monitors for neurogenic shock?
A. Monitor for severe bradycardia every 2 to 4 hours.
B. Monitor the patient every hour for severe hypotension.
C. Assess the patient's breath sounds every 2 to 4 hours.
D. Check if a finger can be inserted between the jacket and the patient's skin.
B. Monitor the patient every hour for severe hypotension.
Rationale
Neurogenic shock occurs due to decreased circulating blood volume following a spinal cord injury. The patient must be monitored at least hourly for severe hypotension to assess for neurogenic shock. The patient's breath sounds should be assessed every 2 to 4 hours to note if the airway is patent and ventilation is adequate. The patient should be monitored for severe bradycardia at least hourly to monitor for neurogenic shock. Inserting a finger between the jacket and the patient's skin ensures that the jacket is not causing pressure.
Which signs/symptoms suggest that a patient's intracranial pressure (ICP) is increasing? Select all that apply.
Select all that apply
A. Vomiting
B. Hypocapnia
C. Dilated pupils
D. Hypoglycemia
E. ICP level of 12 mm Hg
F. Presence of papilledema
A. Vomiting, C. Dilated pupils, F. Presence of papilledema
Rationale
Signs of increasing ICP include an ICP level of greater than 15 mm Hg, the presence of papilledema, dilated pupils, and vomiting. The patient will experience hypercapnia, not hypocapnia. Glucose levels would not be affected.
The registered nurse is teaching a student nurse about the effect of electrical burns on the human body. Which statements made by the student nurse indicate effective learning? Select all that apply.
Select all that apply
A. "Electrical burns cause superficial wounds."
B. "Electrical burns cause full-thickness wounds."
C. "Electrical burns cause deep full-thickness wounds."
D. "Electrical burns cause deep partial-thickness wounds."
E. "Electrical burns cause superficial partial-thickness wounds."
B. "Electrical burns cause full-thickness wounds."
C. "Electrical burns cause deep full-thickness wounds."
Rationale
Electrical burns are a result of an electrical current that enters into the body. Electrical burns cause full-thickness wounds in which the entire epidermis and deeper layers of the dermis get affected, leaving only a few healthy cells. Deep full-thickness wound damage extends beyond the skin even up to the muscles and bones. Electrical burns do not cause superficial wounds. Electrical burns do not result in deep partial-thickness wounds. Similarly, superficial partial-thickness wounds cannot occur as a result of electrical burns, as only the epidermis and upper part of the dermis are affected.
A patient sustained deep partial-thickness burns to the anterior and posterior surface of bilateral lower extremities. Using the rule of nines, which percentage of body surface area does the nurse estimate the patient's burn to be?
A. 9%
B. 18%
C. 36%
D. 40%
C. 36%
Rationale
Using the rule of nines, burns to the anterior and posterior surface of both legs would be about 36% of total body surface area. Each leg is a total of 18%, with each anterior surface being 9% and each posterior surface being 9%.
A patient admitted to the intensive care unit after sustaining a cervical spinal cord injury in a motor vehicle crash is intubated and is receiving mechanical ventilation. The nurse notes a heart rate of 56 beats/min; blood pressure of 88/60 mm Hg; and warm, dry skin. Which priority action does the nurse perform?
A. Continue to assess the patient every 2-4 hours.
B. Increase the oxygen flow to the patient.
C. Notify the provider of these findings immediately.
D. Suction the patient to clear the airway of secretions.
C. Notify the provider of these findings immediately.
Rationale
Neurogenic shock is a potentially life-threatening complication of spinal cord injury in patients with injuries above T6 and is characterized by bradycardia; hypotension; and warm, dry skin. The nurse should notify the provider immediately so that fluids can be restored to the circulating blood volume. Bradycardia is related to shock and not hypoxia, so increasing oxygen or suctioning are not indicated.
Which clinical symptoms are seen in a patient with encephalitis? Select all that apply.
Select all that apply
A. Vertigo
B. Fatigue
C. Photophobia
D. Red macular rash
E. Symptoms of decreased intracranial pressure (ICP)
A. Vertigo, B. Fatigue, C. Photophobia
Rationale
Vertigo, fatigue, and photophobia are clinical manifestations of encephalitis. Red macular rash may be seen in patients with meningitis. Patients with encephalitis will have symptoms of increased ICP.
A patient is seen in the emergency department with a burn to the dorsal and palmar aspect of the hand. The skin is deeply erythematous, with moderate edema throughout. Soft, dry eschar tissue is noted. Which classification of burn injury would the nurse document in the electronic medical record (EMR)?
A. Superficial
B. Full-thickness
C. Deep partial-thickness
D. Superficial partial-thickness
C. Deep partial-thickness
Rationale
Pronounced erythema, moderate edema, and presence of soft, dry eschar are the typical findings in a deep partial-thickness burn injury. Superficial burns have mild erythema and edema, the skin is intact, and there is no eschar. Full-thickness burns have a black or brown coloring of the skin and hard, inelastic eschar. Superficial partial-thickness burns have mild to moderate erythema and edema, but also include blistering. There would not be eschar tissue in a superficial partial-thickness burn injury.
A patient spilled a large open frying pan of hot cooking grease and received burns to the entire anterior chest and abdomen, the entire anterior section of the left arm, and the anterior portion of the left leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines?
A. 25% to 27%
B. 30% to 31%
C. 33% to 45%
D. 40% to 42%
A. 25% to 27%
Rationale
The anterior thorax includes the chest and abdomen, which is 18% of the total body surface area. The anterior surface of the left arm adds another 4.5%, and the anterior section of the left thigh adds another 4.5%, bringing the total body surface area involved in this injury to approximately 25% to 27%.
The nurse is caring for a patient one day after the patient experienced a stroke. The patient is fully alert and has weakness of the right side of the body. Which assessment finding indicates an increasing intracranial pressure (ICP)?
A. The patient is no longer oriented to place.
B. The patient reports numbness of the right leg.
C. The patient has developed urinary incontinence.
D. The patient has a blood pressure of 90/62 mm Hg.
A. The patient is no longer oriented to place.
Rationale
The patient with a recent stroke is at risk of increased intracranial pressure (ICP) because of cerebral edema or ongoing intracranial hemorrhage. The first indication of increasing ICP is a change in the level of consciousness. If the patient is confused and disoriented to place, it indicates an increased ICP, and the primary health care provider should be immediately notified. Urinary incontinence in the patient may indicate focal deficit. Numbness in the right leg may be due to weakness and may be an effect of the stroke, but it does not indicate an increased ICP. A BP of 90/62 mm Hg indicates hypotension. Hypertension is a key feature of increased ICP.
Which clinical manifestations should the nurse assess in a patient who is hospitalized with meningitis? Select all that apply.
Select all that apply
A. Neck stiffness
B. Muscle aches
C. Light sensitivity
D. Retina damage
E. Increased intraocular pressure
A. Neck stiffness, B. Muscle aches, C. Light sensitivity
Rationale
Meningitis is an inflammation of the meninges, specifically the pia mater and arachnoid. The clinical manifestations associated with meningitis include neck stiffness, muscle aches, and light sensitivity. Other manifestations such as retina damage and increased intraocular pressure are not associated with meningitis.
Which assessment data suggest that a patient may have suffered an inhalation injury in addition to a thermal injury from a car explosion? Select all that apply.
Select all that apply
A. Somnolence
B. Reports of thirst
C. Cherry-red cheeks
D. Injury occurred in a closed space
E. Coughing up carbonaceous sputum
F. Burned eyebrows and singed nasal hairs
D. Injury occurred in a closed space
E. Coughing up carbonaceous sputum
F. Burned eyebrows and singed nasal hairs
Rationale
Assessment data suggestive of an inhalation injury include the injury occurring in an enclosed space, the presence of burns to the face and neck, singed facial hair, carbonaceous sputum, hoarseness or brassy cough, drooling, and wheezing. Cherry-red cheeks and somnolence are more suggestive of carbon monoxide poisoning. Reports of thirst are likely with any type of burn injury as a result of fluid shifting. This would not be specific to an inhalation or thermal burn injury.
The nurse is reviewing the orders for a patient admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider?
A. Daily weights
B. Hold omeprazole
C. Activity as tolerated
D. Fentanyl 50 mcg IV every 4 hours PRN for pain
B. Hold omeprazole
Rationale
The nurse should question the order to hold omeprazole, a proton pump inhibitor agent. Patients with burn injury are at increased risk of developing an acute gastroduodenal ulcer (Curling's ulcer) within the first 24 hours after a severe burn injury because of reduced blood flow to the gastrointestinal tract and mucosal lining damage. Proton pump inhibitors and H 2-histamine blocking agents along with early enteral feedings are important interventions to prevent this complication. Daily weights, IV opioid agents for pain management, and activity orders are appropriate for patients with burn injuries.