Neu
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?
a. Both pressures are high.
b. Both pressures are low.
c. ICP is high; CPP is normal.
d. ICP is high; CPP is low.
ANS: C
The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.
Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that Apply)
a. Administer levothyroxine as ordered.
b. Encourage the intake of foods high in sodium.
c. Initiate passive re-warming interventions.
d. Monitor airway and respiratory effort.
e. Monitor urine osmolality.
ANS: A, C, D
Myxedema coma is a severe manifestation of hypothyroidism. Treatment entails replacement of thyroid hormone, airway management related to respiratory depression and potential airway obstruction related to tongue edema, thermoregulation, management of edema and congestive heart failure symptoms, and patient education. Edema may accompany myxedema and necessitate use of sodium restriction. Urine osmolality is monitored in conditions that affect antidiuretic hormone levels
An older adult 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
ANS: D
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.
Which clinical manifestation would the nurse expect to assess in a patient with bacterial meningitis? (Select all that Apply)
Ans: A, B, D, E
Kernig sign is an indication of meningitis. Meningitis can cause a rash which is typically macular at first. Brudzinski sign is an indicator of meningitis. As cortical involvement occurs, the patient may have decreased level of consciousness. Meningitis does not cause decreased pupillary response.
Which intervention would a nurse expect to implement for a patient diagnosed with myxedema coma? (Select all that Apply)
Ans: A, B, D, E, F
Passive warming blankets are used to help maintain the patient's temperature. Patients with hypothyroidism are unable to maintain body heat due to decreased metabolic rate and production of thermal energy. Hydrocortisone is administered to replace the hormones that would normally be secreted by the adrenal gland. The patient needs to be assessed for pleural effusions due to the retention of water that is associated with myxedema coma. Ventilatory assistance is needed because there is depression of the respiratory system. This occurs due to the muscle weakness associated with myxedema coma. An echocardiogram is done to assess cardiac function. There is depression of the cardiac system and myxedema coma. This is associated with decreased cardiac output, heart rate, and blood pressure. Medications that affect the nervous system can worsen myxedema coma. Sedatives and narcotics should be avoided.
A nurse is caring for a patient with a closed head injury and increasing intracranial pressure. Which of the following manifestations does the nurse report to the health care provider that represents Cushing's triad? (Select all that Apply)
Ans: B, C, E
Cushing's triad consists of bradycardia, irregular respirations, and a widening pulse pressure (increasing systolic) The pulse is full and bounding, not weak. The systolic blood pressure increases, not decreases.
The nurse assesses a patient who presents with symptoms of hyperparathyroidism. Which questions does the nurse ask the patient during the assessment? (Select all that Apply)
Ans: B, D, E
When a patient is suspected of hyperparathyroidism the nurse should ask the patient about any bone fractures, recent weight loss, and radiation treatment to the neck or head. Asking about lung infections and blood transfusions does not help the nurse assess the patient for hyperparathyroidism.
The patient has been prescribed Lugol's solution. The nurse knows that Lugol's solution helps block _______ of thyroid hormones in thyroid storm and that_____ is a common side effect of this medication.
Ans: C
The 2nd form of treatment in thyroid crisis is to block the thyroid hormone release. This is mainly because the antithyroid medications don't have an immediate effect. These patients will be given some sort of inorganic iodine, and this is going to block the release of T4 from the thyroid. Iodine is available as saturated solution of potassium iodine (SSKI) and Lugol's solution. It is mixed with water or juice, sipped through a straw and given after meals to improve its taste. Nausea, vomiting, and a metallic taste in the mouth are common side effects.
What differences would you expect to see in patients experiencing hyperosmolar hyperglycemic syndrome rather than diabetic ketoacidosis?
a. Lower serum glucose, lower osmolality, and greater ketosis
b. Lower serum glucose, lower osmolality, and milder ketosis
c. Higher serum glucose, higher osmolality, and greater ketosis
d. Higher serum glucose, higher osmolality, and no ketosis
ANS: D
In patients with hyperosmolar hyperglycemic syndrome (HHS), glucose is higher; osmotic diuresis is greater, resulting in higher osmolality; and ketosis is usually absent. Glucose values in HHS are typically higher than those of diabetic ketoacidosis and are not typically accompanied by ketosis.
The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse?
a. Administer over 2 minutes.
b. Administer over 5 minutes.
c. Mix medication with 0.9% normal saline.
d. Administer via central line.
ANS: B
In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario.
Mr. M is a 32-year-old man brought to the emergency department (ED) by paramedics after a fall from the second story roof of his home. He was placed on a spinal board with a cervical collar to immobilize his spine. After spinal X-rays are obtained, the health care provider (HCP) determines that he has a spinal cord injury at the C4 to C5 level. The ED nurse assists the ED HCP in testing Mr. M's deep tendon reflexes (DRs), which are all absent. What does the nurse suspect is the likely cause of the absent DTRs?
The nurse caring for a patient who experienced a head trauma following a fall notes that the patient’s heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor, dry mucous membranes and appears confused and restless.
The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder?
a. Cerebral salt wasting
b. Diabetes insipidus
c. Syndrome of inappropriate secretion of antidiuretic hormone
d. Thyroid storm
ANS: A
Cerebral salt wasting may occur after head trauma and is characterized by low sodium in the face of classic physical and laboratory signs of fluid volume deficit or dehydration, including tachycardia, hypotension, dry mucous membranes, weight loss, and poor skin turgor. The patient also may experience the classic signs of hyponatremia, including a serum sodium less than 135 mg/dL, confusion, lethargy, seizures, and coma. Diabetes insipidus is characterized by clinical signs of dehydration with elevated serum sodium. SIADH is characterized by hyponatremia and fluid volume overload. Thyroid storm would not directly affect sodium levels.
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?
a. Administer acetaminophen as ordered for the headache.
b. Assess for a kinked urinary catheter and assess for bowel impaction.
c. Encourage the patient to take slow, deep breaths.
d. Notify the physician of the patient’s blood pressure.
ANS: B
Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distention. Other causes that should be ruled out
prior to pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow deep breathes will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician.
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 should the nurse implement first?
a. Obtain stat serum electrolytes.
b. Administer lorazepam.
c. Obtain stat portable chest x-ray.
d. Administer phenytoin.
ANS: B
The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticus. Phenytoin 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.
Which nursing diagnosis is a high-priority for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?
a. Activity intolerance
b. Fluid volume deficient
c. Hyperthermia
d. Impaired nutrition, more than body requirements
ANS: B
Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia; therefore, fluid volume deficit is a priority nursing diagnosis. Even though activity intolerance is a potential nursing diagnosis related to the fatigue associated with metabolic changes in hyperglycemic conditions, it is not a first priority. Hyperthermia is associated with thyroid crisis. Although overweight and obesity are risk factors for type 2 diabetes, during metabolic crisis, the patient has inadequate energy available to tissues because of limited availability and poor utilization of insulin.
Which action does the nurse take before initiating prescribed insulin therapy to a patient in diabetic ketoacidosis (DKA)? (Select all that Apply)
Ans: A, E
Fluid replacement must be underway, and the serum potassium level must be greater than 3.3 before insulin therapy can be administered to a patient in DKA. There is no need to evaluate the BUN or osmolality. Vital signs would be assessed at least every hour until the patient is stable. There is no need to reassess v/s immediately before implementing insulin therapy.
Which intervention does the nurse expect on the care plan of a patient with type 2 diabetes being treated for hyperglycemic hyperosmolar state (HHS)? (Select all that Apply)
Ans: B, D, E
Nursing management of the patient with HHS will focus on fluid balance and blood glucose measurement. Hourly urine output is an indicator of kidney function and provides information to prevent overhydration or insufficient hydration. Strict I/O should be measured to monitor for fluid balance and kidney functioning. Blood pressure should be measured every 4 hours to evaluate the effectiveness of hydration therapy and determine the patient’s tolerance to the fluids. Continuous cardiac monitoring is needed due to the increased risk of ventricular dysrhythmias. Serum glucose should be monitored every hour while receiving an insulin infusion to determine the effectiveness of insulin therapy and adjusted as needed to prevent the development of hypoglycemia.
Which hourly assessment would the nurse include in the plan of care for a patient with increased intracranial pressure. (Select all that Apply)
Ans: C, D, E
A focal motor assessment, Glasgow Coma Scale, and assessment of the pupils are included in the hourly assessment of a patient with ICP. The spinal nerves and dermatomes are not specifically included in the hourly assessment of a patient with increased ICP.
Which intervention does the nurse expect on the care plan of a patient with type 2 diabetes being treated for hyperglycemic hyperosmolar state (HHS)? (Select all that Apply)
Ans: B, D, E
Nursing management of the patient with HHS will focus on fluid balance and blood glucose measurement. Hourly urine output is an indicator of kidney function and provides information to prevent overhydration or insufficient hydration. Strict I/O should be measured to monitor for fluid balance and kidney functioning. Blood pressure should be measured every 4 hours to evaluate the effectiveness of hydration therapy and determine the patient’s tolerance to the fluids. Continuous cardiac monitoring is needed due to the increased risk of ventricular dysrhythmias. Serum glucose should be monitored every hour while receiving an insulin infusion to determine the effectiveness of insulin therapy and adjusted as needed to prevent the development of hypoglycemia.
Which clinical presentation differentiates diabetic ketoacidosis (DA) from a hyperosmolar hyperglycemic state (HHS)? (Select all that Apply)
Ans: A, E
Polydipsia and abdominal pain occur in DKA but are not characteristic of HHS. The other options are clinical findings in both DKA and HHS.
Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.)
a. ADH deficiency
b. ADH excess
c. ADH insensitivity
d. ADH replacement therapy
e. Water deprivation
ANS: A, C
Diabetes insipidus is caused by either a deficiency in ADH production (neurogenic) or impaired renal response to ADH (nephrogenic). ADH excess is characteristic of syndrome of inappropriate secretion of antidiuretic hormone. ADH replacement therapy is a treatment for neurogenic diabetes insipidus. Water deprivation would result in increased ADH secretion and further augment dehydration associated with diabetes insipidus.
Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone?
a. Fasting blood glucose 156 mg/dL
b. Serum potassium 5.8 mEq/L
c. Serum sodium 115 mEq/L
d. Serum sodium 152 mEq/L
ANS: C
SIADH causes a dilutional hyponatremia, and central nervous system symptoms can occur. A low serum sodium (below 135 mEq/L) may accompany the syndrome. Glucose elevation is not a classic sign of SIADH. Hyperkalemia does not accompany the dilutional hyponatremia of SIADH. Serum sodium levels are typically lower in the dilutional hyponatremia that accompanies SIADH.
What is the most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance?
a. Fluid volume excess
b. Hyperglycemia.
c. Hyperkalemia
d. Hypernatremia
ANS: C
Adrenal insufficiency may be characterized by inadequate amounts of cortisol and aldosterone. Aldosterone acts to retain sodium, resulting is water retention and potassium loss. Inadequate levels of aldosterone therefore result in hyponatremia, fluid loss, and hyperkalemia. Inadequate cortisol levels may cause weight loss, weakness, and hypoglycemia. Fluid volume deficit may accompany adrenal crisis as a result of sodium loss from decreases in cortisol and aldosterone. Hypoglycemia may accompany adrenal crisis as a consequence of inadequate amounts of cortisol, which limits gluconeogenesis. Hyponatremia may accompany adrenal crisis because of sodium losses secondary to aldosterone insufficiency that often accompanies the condition.
A physician orders Calcium Gluconate IV as treatment for a patient with hypoparathyroidism. The patient’s calcium level is 5. Which of the following findings causes you to question the order?
Ans: A
Calcium gluconate can increase Digoxin toxicity.
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 what complication of the injury?
a. Diabetes insipidus
b. Diabetic ketoacidosis
c. Hyperosmolar hyperglycemic syndrome
d. Syndrome of inappropriate secretion of antidiuretic hormone
ANS: A
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.