Use Your Head
Which patient below is at MOST risk for developing cardiogenic shock?
A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish.
B. A 25-year-old female who has experienced an upper thoracic spinal cord injury.
C. A 72-year-old male who is post-op from a liver transplant.
D. A 49-year-old female who is experiencing an acute myocardial infarction.
D. An acute MI (heart attack) is the main cause of cardiogenic shock.
Rationale: It happens because a coronary artery has become blocked. Coronary arteries supply the heart muscle’s cells with oxygenated blood. If they don’t receive this oxygenated blood they will die, which causes the heart muscle to quit working (hence pumping efficiently). When the heart muscle fails to pump efficiently, cardiac output fails and cardiogenic shock occur.
As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient’s urine for:
A. Hemoglobin and myoglobin
B. Free iron and white blood cells
C. Protein and red blood cells
D. Potassium and Urea
A. Patients who’ve experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient’s urine for these substances.
You’re providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority?
A. Keeping the head of the bed greater than 45 degrees at all times.
B. Repositioning the patient every thirty minutes.
C. Keeping the patient’s spine immobilized.
D. Avoiding log-rolling the patient during transport.
C. Keeping the patient’s spine immobilized.
Rationale: It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient’s spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.
A nurse receives report on four clients at the start of shift. Which client requires the most immediate assessment?
A. A client recovering from a concussion who reports a persistent headache and difficulty sleeping.
B. A client being treated for meningitis who is newly difficult to arouse.
C. A client with a stable skull fracture who reports intermittent nausea.
D. A client with a mild head injury who reports dizziness when standing.
Answer: B. A client being treated for meningitis who is newly difficult to arouse.
Rationale: A new decrease in level of consciousness is an acute neurologic change and may indicate worsening cerebral involvement or increased intracranial pressure. The other findings are less immediately concerning.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
A. Test the drainage for glucose
B. Suction the nostrils
C. Notify the physician
D. Ask the client to blow their nose
A. Test the drainage for glucose.
Answer Rationale:
This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.
A client is being monitored after sustaining a traumatic brain injury. Which set of vital signs should the nurse recognize as the most concerning for increased intracranial pressure?
A. HR 88, RR 28, BP 134/76 mm Hg
B. HR 72, RR 24, BP 142/82 mm Hg
C. HR 116, RR 22, BP 108/68 mm Hg
D. HR 54, RR 12, BP 172/58 mm Hg
D. HR 54, RR 12, BP 172/58 mm Hg
Rationale: Bradycardia, slowed respirations, and a widened pulse pressure are consistent with Cushing’s triad, a late sign of increased intracranial pressure.
A nurse is admitting a client after a residential fire. The client has extensive partial- and full-thickness burns involving the upper torso and both arms. Which finding requires the most immediate follow-up?
A. Burns involving approximately one-third of the client’s total body surface area
B. Clear breath sounds heard throughout the lung fields
C. Long-term use of medication that suppresses the immune system
D. Bright red discoloration of the skin and face
Answer: D. Bright red discoloration of the skin and face.
Rationale: A cherry-red appearance after smoke exposure can indicate carbon monoxide poisoning, which requires immediate treatment with high-flow oxygen. This finding takes priority because carbon monoxide interferes with oxygen delivery to tissues.
The nurse is receiving report on several clients. Which client should the nurse recognize as being at greatest risk for developing distributive shock?
A. A client with a bleeding disorder who received clotting factor replacement earlier today
B. A client who developed renal impairment several days after orthopedic surgery
C. A client admitted after a high-level spinal cord injury sustained in a fall
D. A client who developed a serious dysrhythmia after an acute myocardial infarction
Answer: C. A client admitted after a high-level spinal cord injury sustained in a fall.
Rationale: A high spinal cord injury can cause neurogenic shock, which is a type of distributive shock resulting from loss of sympathetic tone and widespread vasodilation.
A nurse on a burn unit is reviewing updates on four clients. Which client should the nurse assess first?
A. A client whose oral intake has remained below the prescribed high-calorie diet for several days
B. A client who has declined scheduled range-of-motion therapy twice
C. A client whose burn wound now has increasing redness and swelling extending into previously unaffected skin
D. A client with a penicillin allergy who has an order for topical gentamicin
Answer: C. A client whose burn wound now has increasing redness and swelling extending into previously unaffected skin.
Rationale: Redness and edema spreading beyond the burn wound can indicate a developing infection or cellulitis. Because infection can progress rapidly in burn clients, this finding requires priority follow-up.
A client is being monitored after a fall that caused both a head injury and a suspected cervical spine injury. Which nursing action is most appropriate?
A. Maintain the head and neck in a neutral, aligned position.
B. Place the client in Trendelenburg position to support cerebral perfusion.
C. Flex the client’s hips during repositioning to improve comfort.
D. Notify the provider for a PaCO₂ of 36 mm Hg.
Answer: A. Maintain the head and neck in a neutral, aligned position.
Rationale: Keeping the head and neck in neutral alignment helps protect the cervical spine and promotes venous drainage from the brain. Trendelenburg positioning and hip flexion can increase ICP, while a PaCO₂ of 36 mm Hg is within the expected range.
A client with increased intracranial pressure (ICP) is prescribed an osmotic diuretic to reduce cerebral edema. The nurse should anticipate administering __________________.
Answer: Mannitol
Rationale: Mannitol is an osmotic diuretic that pulls fluid from swollen brain tissue into the bloodstream, helping decrease cerebral edema and intracranial pressure. The nurse should monitor fluid status, electrolytes, renal function, and serum osmolality during therapy.
A client who was rescued from a house fire is confused and reports a headache and nausea. The client's oxygen saturation is 99% on room air by pulse oximetry. The nurse notes soot on the client's clothing but no visible burns. Which action should the nurse take?
A. Document that carbon monoxide poisoning is unlikely because the pulse oximetry reading is normal.
B. Apply high-flow oxygen and notify the provider that carbon monoxide poisoning is suspected.
C. Encourage the client to ambulate in the hallway to improve ventilation.
D. Administer an antiemetic and reassess the client after nausea improves.
Answer: B Apply high-flow oxygen and notify the provider that carbon monoxide poisoning is suspected.
Rationale: Carbon monoxide poisoning can cause headache, nausea, confusion, and falsely normal pulse oximetry readings because standard pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin. High-flow oxygen is indicated while notifying the provider.
A nurse is caring for a postoperative client who is showing signs of hypovolemic shock after significant blood loss. Which position is most appropriate to support circulation?
A. Flat on the back with the legs resting at bed level
B. Head of the bed kept low while the legs are elevated
C. Head of the bed elevated to 45 degrees with the knees bent
D. Side-lying with the head of the bed slightly elevated
Answer: B. Head of the bed kept low while the legs are elevated.
Rationale: Keeping the head of the bed low and elevating the legs can help improve venous return and support circulation in hypovolemic shock.
A nurse is assigned to care for four clients on a neurologic step-down unit. Which client should the nurse assess first?
A. A client who has a concussion and reports a mild headache that improves after acetaminophen.
B. A client who has a basilar skull fracture and clear fluid draining from the ear onto the pillowcase.
C. A client who had a seizure disorder prior to admission and is requesting the prescribed morning antiseizure medication.
D. A client who has a spinal cord injury at T10 and reports feeling frustrated about needing assistance with repositioning.
Answer: B A client who has a basilar skull fracture and clear fluid draining from the ear onto the pillowcase.
Rationale: Clear drainage from the ear after a basilar skull fracture may indicate cerebrospinal fluid leakage, which increases the risk for meningitis and requires prompt assessment and provider notification.
The nurse is caring for a client following an abdominal aortic aneurysm (AAA) repair. Which finding is most concerning for hypovolemic shock?
A. Pupils increase from 4 mm to 6 mm
B. Respiratory rate decreases from 28/min to 14/min
C. Mean arterial pressure increases above baseline
D. Serum lactate level is 8 mmol/L
Answer: D. Serum lactate level is 8 mmol/L
Rationale: A lactate level of 8 mmol/L is significantly elevated and suggests severe tissue hypoperfusion. In hypovolemic shock, decreased circulating volume reduces oxygen delivery to tissues, causing anaerobic metabolism and increased lactate production. After AAA repair, this finding should raise concern for significant blood loss or internal bleeding.
The nurse is caring for a client with a basilar skull fracture. Which finding requires the most immediate follow-up?
A. Reports tinnitus and decreased hearing in one ear
B. Reports a persistent headache that worsens when sitting upright
C. Develops new pupillary asymmetry with decreased responsiveness
D. Has bruising behind the ear and tenderness over the mastoid area
Answer: C Develops new pupillary asymmetry with decreased responsiveness
Rationale: New pupillary asymmetry accompanied by decreased level of consciousness may indicate increasing intracranial pressure, cerebral edema, or brain herniation. These findings represent acute neurologic deterioration and require immediate intervention. Tinnitus and Battle sign can occur with basilar skull fractures, while headache is common after head injury, but none are as immediately concerning as a new change in pupils and responsiveness.
The nurse is caring for a client who sustained an electrical injury. Which assessment is the priority?
A. Assess the client’s pulse rate and rhythm and obtain an ECG
B. Inspect the entrance and exit wound sites and obtain cardiac enzymes
C. Assess the pupils for response to light and anisocoria
D. Review medication allergies and initiate prescribed IV fluids
Answer: A Assess the client’s pulse rate and rhythm and obtain an ECG
Rationale: Electrical injuries can disrupt the heart’s electrical conduction system and cause potentially life-threatening cardiac dysrhythmias, even when external burns appear minor. The nurse should first assess the client’s heart rate and rhythm and obtain an ECG. Assessment of burn sites, neurologic status, and fluid needs is also important, but identifying an immediate cardiac complication takes priority.
A 79-year-old client with a stage 3 sacral pressure ulcer is at greatest risk for developing __________________ shock.
Answer: Septic or Distributive Shock
Rationale: A stage 3 pressure ulcer creates a significant break in the skin and increases the risk for infection. In an older adult, that infection can progress to sepsis and septic shock. Septic shock is classified as distributive shock because widespread vasodilation and increased capillary permeability cause blood to be poorly distributed to the tissues, leading to decreased tissue perfusion and hypotension.
The nurse is caring for four clients on a burn step-down unit. Which client should the nurse assess first?
A. A client with 30% TBSA burns who has a urine output of 35 mL/hr for the past 2 hours
B. A client with circumferential burns to the right arm who reports increasing pain despite opioid medication and has a weak radial pulse
C. A client with partial-thickness burns who has a temperature of 38.1°C (100.6°F) and a heart rate of 108/min
D. A client with full-thickness burns to the chest who reports pain of 7/10 during a dressing change
Answer: B A client with circumferential burns to the right arm who reports increasing pain despite opioid medication and has a weak radial pulse
Rationale: The client with circumferential burns who has increasing pain and a weak distal pulse is showing signs of impaired circulation from swelling beneath the burned tissue. This can progress to compartment syndrome and loss of perfusion to the extremity, making this client the priority. A urine output of 35 mL/hr is acceptable for an adult, mild fever and tachycardia can occur with the hypermetabolic response to burns, and pain during dressing changes is expected.
The nurse is reviewing discharge instructions with the partner of a client who sustained a mild head injury. Which statement by the partner indicates a need for further teaching?
A. “I’ll encourage my partner to rest and avoid strenuous activity for the next 48 hours.”
B. “I’ll avoid giving sedating medications unless specifically instructed by the provider.”
C. “I’ll watch for worsening headache, repeated vomiting, confusion, or changes in behavior.”
D. “I’ll wake my partner every hour throughout the night to make sure they can answer questions appropriately.”
Answer: D
Rationale: A client with a mild head injury does not routinely need to be awakened every hour throughout the night if the provider has determined the client is safe for discharge. Rest is important for recovery. The partner should instead monitor for signs of neurologic deterioration, including worsening headache, repeated vomiting, increasing confusion, unusual behavior, difficulty awakening, or other changes in neurologic status. Sedating medications should generally be avoided unless specifically approved because they can mask changes in level of consciousness.
A client presents to the emergency department with a sudden onset of severe headache, photophobia, and confusion. The nurse’s priority action is to ______________________________.
Answer: Perform a focused neurologic assessment.
Rationale: Sudden severe headache, photophobia, and confusion can signal an acute neurologic emergency. The nurse should first assess neurologic status to identify changes in level of consciousness, pupil response, motor function, and other signs of deterioration. Pain medication and environmental changes may be appropriate later, but assessment takes priority before intervention.
A client has a burn injury that extends through the epidermis, dermis, subcutaneous tissue, and into the underlying muscle and bone. This injury is classified as a __________________ burn.
Answer: Fourth-degree burn
Rationale: A fourth-degree burn extends beyond the full thickness of the skin and subcutaneous tissue into deeper structures such as muscle, tendon, or bone. These burns are extremely severe and may appear charred or blackened. Because nerve endings may be destroyed, the deepest portion of the burn may have little or no sensation.
A client has received aggressive treatment for septic shock for the past 24 hours. The client is now anuric, unresponsive, and has fixed, dilated pupils despite vasopressor therapy. The client has progressed to the __________________ stage of shock.
Answer: Refractory Stage
Rationale: The refractory stage of shock is characterized by severe, irreversible organ dysfunction despite aggressive treatment. Findings such as anuria, fixed and dilated pupils, and unresponsiveness despite vasopressors indicate profound tissue hypoperfusion and failure of multiple organ systems. At this stage, the body is no longer able to compensate, and treatment is often ineffective.
The nurse receives report on four clients. Which client should the nurse assess first?
A. A client with septic shock receiving norepinephrine who has a MAP of 67 mm Hg and urine output of 32 mL/hr
B. A client with a circumferential full-thickness burn to the chest who has increasing work of breathing and diminished chest expansion
C. A client with a traumatic brain injury who has a Glasgow Coma Scale score that decreased from 14 to 12 over the last hour
D. A client with hypovolemic shock who has a heart rate of 118/min and capillary refill of 3 seconds after receiving an IV fluid bolus
Answer: B. A client with a circumferential full-thickness burn to the chest who has increasing work of breathing and diminished chest expansion
Rationale: A circumferential full-thickness chest burn can form a rigid eschar that restricts chest wall expansion and prevents adequate ventilation. Increasing work of breathing with diminished chest expansion suggests impaired ventilation and impending respiratory compromise, making this client the priority. The client may require an emergency escharotomy to restore chest expansion. The neurologic decline in option C is also concerning, but an active threat to breathing takes priority. The findings in A and D indicate clients who remain abnormal but are currently showing evidence of perfusion or response to treatment.
A client with a traumatic brain injury develops increasing systolic blood pressure with a widening pulse pressure, bradycardia, and irregular respirations. These findings are collectively known as ______________________________.
Answer: Cushing’s Triad
Rationale: Cushing’s Triad is a late sign of significantly increased intracranial pressure and consists of widening pulse pressure, bradycardia, and irregular respirations. It suggests worsening brain compression and possible impending herniation, requiring immediate intervention.