Neuro
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
An elderly client with pneumonia may appear with which of the following symptoms first?
A. Altered mental status and dehydration
Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response. A small fraction of patients may have an altered mental status, abdominal pain, chest pain, and other systemic findings.
A client who is taking famotidine (Pepcid) asks the nurse what would be the best medication to take for a headache. The nurse tells the client that it would be best to take:
C. acetaminophen (Tylenol)
The client is taking famotidine, a histamine receptor antagonist. This implies that the client has a disorder characterized by gastrointestinal (GI) irritation. The only medication of the ones listed in the options that is not irritating to the GI tract is acetaminophen. The other medications could aggravate an already existing GI problem. Acetaminophen (APAP) is considered a non-opioid analgesic and antipyretic agent used to treat pain and fever. Clinicians can use it for their patients as a single agent for mild to moderate pain and in combination with an opioid analgesic for severe pain.
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. The best response to this client should be:
C. “The medication must be continued so the fluid problem is controlled.”
This is the most therapeutic response and gives the client accurate information. Diuretics are used to achieve and maintain euvolemia (the patient’s ‘dry weight’) with the lowest possible dose. This means that the dose must be adjusted, particularly after the restoration of the dry body weight, to avoid the risk of dehydration, which leads to hypotension and renal dysfunction.
When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse?
C. Sterile technique for dressing change at IV site.
Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are a good medium for bacterial growth. Strict sterile technique is crucial in preventing infection at IV infusion sites. Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skin care around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates.
Which description of an acute embolic stroke given by the nurse is most accurate?
A) The local cerebral tissue becomes engorged with blood from a ruptured cerebral vessel.
B) A blood clot lodges in a cerebral vessel and blocks blood flow.
C) Infarcted areas in the brain slough off, leaving cavities in the brain tissue.
D) Cerebral vascular pressure exceeds the elasticity of the vessel wall, resulting in hemorrhages.
B) A blood clot lodges in a cerebral vessel and blocks blood flow.
In embolic stroke, a blood clot or other matter traveling through cerebral blood vessels becomes lodged in a narrow vessel blocking blood flow. The area of the brain supplied by the blocked vessel becomes ischemic. The clot may originate from a thrombus formed in the left side of the heart during atrial fibrillation, bacterial endocarditis, recent myocardial infarction (MI), atherosclerotic plaque from the carotid artery, rheumatic heart disease, or ventricular aneurysm.
A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests?
D. Sputum culture and sensitivity
Sputum C & S is the best way to identify the organism causing the pneumonia. If good quality, sputum evaluation may reveal more than 25 WBC per low-power field and less than 10 squamous epithelial cells. Some bacterial causes present with specific biochemical evidence, such as Legionella, may present with hyponatremia and microhematuria.
The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse’s immediate action?
C. Complaints of pain at the site of infusion.
A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants that cause pain along the vein wall, with or without inflammation.
Which of the following blood tests is most indicative of cardiac damage?
A. Troponin I
Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin levels aren’t detectable in people without cardiac injury. Anything that causes damage to cardiac muscle can cause troponin to spill into the circulation. The most common cause of injury is oxygen supply and demand mismatch, which is seen in acute myocardial infarction.
An order is written to start an IV on a 74-year-old client who is getting ready to go to the operating room for a total hip replacement. What gauge of catheter would best meet the needs of this client?
A. 18
Clients going to the operating room ideally should have an 18- gauge catheter. This is large enough to handle blood products safely and to allow rapid administration of large amounts of fluid if indicated during the perioperative period. An 18-gauge catheter is recommended.
An adult client had a stroke involving the internal carotid artery of the dominant hemisphere. The nurse should anticipate that the client will have difficulty with which function?
A) Speaking
B) Staying alert
C) Retaining urine
D) Swallowing
A) Speaking
Clinical manifestations of a stroke involving the internal carotid artery include contralateral paralysis of face and limbs, contralateral sensory deficits of face and limbs, aphasia, apraxia, agnosia, unilateral neglect, and homonymous hemianopia. Difficulty swallowing, drowsiness, and urine retention are not expected in this type of stroke.
A client has active TB. Which of the following symptoms will he exhibit?
B. Chills, fever, night sweats, and hemoptysis
Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Constitutional symptoms like fever, weight loss, lymphadenopathy, and night sweats are commonly reported. Extrapulmonary tuberculosis can affect any organ and can have a varied presentation. In pulmonary tuberculosis, the most commonly reported symptom is a chronic cough. Cough most of the time is productive, sometimes mixed with blood.
A client with advanced cirrhosis of the liver is not tolerating protein well, as evidenced by abnormal laboratory values. The nurse anticipates that which of the following medications will be prescribed for the client?
A. lactulose (Chronulac)
The client with cirrhosis has impaired ability to metabolize protein because of liver dysfunction. Administration of lactulose aids in the clearance of ammonia via the gastrointestinal (GI) tract.
A 57-year-old client with a history of asthma is prescribed propranolol (Inderal) to control hypertension. Before administered propranolol, which of the following actions should the nurse take first?
C. Question the physician about the order.
Propranolol and other beta-adrenergic blockers are contraindicated in a client with asthma, so the nurse should question the physician before giving the dose. Propranolol is also contraindicated in those with any lung pathologies, such as COPD, asthma, or emphysema. The pathophysiology of this mechanism is solely due to the effects that beta-2 receptors have on lung function. Normally, activation of beta-2 receptors vasodilates the smooth muscle in the lungs. When using agents like propranolol in patients with underlying lung issues, the blockage of beta-2 causes vasoconstriction of smooth muscle, worsening respiratory function.
The physician orders penicillin for a patient with streptococcal pharyngitis. The nurse administers the drug as ordered, and the patient has an allergic reaction. The nurse checks the medication order sheet and finds that the patient is allergic to penicillin. Legal responsibility for the error is:
D. The pharmacist, physician, and nurse are all liable for the mistake.
The physician, nurse, and pharmacist all are licensed professionals and share responsibility for errors. The legal response to medical errors that do gain legal consideration is typically dominated by one or more of three goals: compensation, accountability, and retribution. These each feature, with greater or lesser emphasis, in different national, legal, and regulatory regimes
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be the nurse NOT perform for for this client?
Which of the following organisms most commonly causes community-acquired pneumonia in adults?
C. Streptococcus pneumoniae
Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae, is the most common cause of community-acquired pneumonia. Streptococcus pneumoniae is the bacterium that has historically been the most common pathogen to cause CAP worldwide. In the era before antibiotics, S. pneumoniae was estimated to be the cause of 95% of all cases of pneumonia. Currently, however, S. pneumoniae accounts for up to 15% of pneumonia cases in the United States and 27% of cases worldwide today.
H. influenzae is the most common cause of infection in children.
Staphylococcus aureus is the most common cause of hospital-acquired pneumonia. Klebsiella species is the most common gram-negative organism found in the hospital setting
James Perez, a nurse on a geriatric floor, is administering a dose of digoxin to one of his patients. The woman asks why she takes a different pill than her niece, who also has heart trouble. James replies that as people get older, liver and kidney function decline, and if the dose is as high as her niece’s, the drug will tend to:
B. Accumulate.
The decreased circulation to the kidney and reduced liver function tend to allow drugs to accumulate and have toxic effects. Physiologic changes and disease associated with aging have an impact on pharmacokinetics and pharmacodynamics of medications. Altered drug response and increased adverse reactions are common amongst the elderly. The narrow therapeutic index of digoxin and pharmacokinetic changes associated with aging increases the risk of toxicity. The most important age-related change is that of deterioration of renal function and this is especially true for digoxin where poorer renal excretion demands lower dosage to avoid toxicity.
One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect?
C. Hypokalemia
Furosemide is a potassium-depleting diuretic that can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia. Hypokalemia can result in a variety of cardiac dysrhythmias. Although cardiac dysrhythmias or ECG changes are more likely to be associated with moderate to severe hypokalemia, there is a high degree of individual variability and can occur with even mild decreases in serum levels.
A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which of the following interventions is important?
A. Strain all urine.
Urine should be strained for calculi and sent to the lab for analysis. Strain all urine. Document any stones expelled and sent to the laboratory for analysis. Retrieval of calculi allows identification of type of stone and influences choice of therapy.
The nurse is reviewing interventions aimed at maintaining cerebral perfusion in a client who had a thrombotic stroke. Which intervention should the nurse question?
A) Encouraging active range-of-motion exercises
B) Placing the client in a side-lying position w/ HOB at 30 degrees
C) Monitoring mental status and level of consciousness
D) Monitoring respiratory status
A) Encouraging active range-of-motion exercises
Active range-of-motion exercises promote physical mobility but will not directly assist in maintaining cerebral perfusion. The initial focus of care is to identify changes in airway, breathing, and circulation that could indicate decreased cerebral perfusion. Maintaining adequate oxygenation and positioning to facilitate breathing is appropriate.
A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid-base imbalance?
A. Respiratory acidosis
Respiratory acidosis is most often due to hypoventilation. Chronic respiratory acidosis is most commonly caused by COPD. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships. Respiratory acidosis is a state in which there is usually a failure of ventilation and an accumulation of carbon dioxide. The primary disturbance of elevated arterial PCO2 is the decreased ratio of arterial bicarbonate to arterial PCO2, which leads to a lowering of the pH.
Mr. Jessie Ray, a newly admitted patient, has a seizure disorder which is being treated with medication. Which of the following drugs would the nurse question if ordered for him?
B. amitriptyline (Elavil), 10 mg QI
Elavil is an antidepressant that lowers the seizure threshold, so would not be appropriate for this patient. The other medications are anti-seizure drugs. The risk of epilepsy/seizures is significantly increased for all classes of antidepressants. There is a need for individual risk-benefit assessments in patients being considered for antidepressant treatment, especially those with ongoing mild depression or with additional risk factors.
Which of the following types of angina is most closely related with an impending MI?
D. Unstable angina
Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months. Evidence shows that patients with new-onset ST-segment elevation (more than 1 mm) have a 12-month rate of an MI or death of about 11%, compared to only 7% for patients who only have isolated inversion of the T wave. Unstable angina results when the blood flow is impeded to the myocardium. Most commonly, this block can be from intraluminal plaque formation, intraluminal thrombosis, vasospasm, and elevated blood pressure.
A client had a transurethral prostatectomy for benign prostatic hypertrophy. He’s currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the interventions should be done first?
D. Check for the presence of clots, and make sure the catheter is draining properly.
Blood clots and blocked outflow of urine can increase spasms. Bladder irrigation helps remove and prevent blood clots in the bladder. The blood clots stop urine from flowing through the catheter. The urine collects in the bladder and causes pain that gets worse as the bladder fills.