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You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:
A. Hemianopia
B. Opticopsia
C. Apraxia
D. Ataxia
A. Hemianopia
A 25 year-old presents to the ER with unexplained paralysis from the hips downward. The patient explains that a few days ago her feet were feeling weird and she had trouble walking and now she is unable to move her lower extremities. The patient reports suffering an illness about 2 weeks ago, but has no other health history. The physician suspects Guillain-Barré Syndrome and orders some diagnostic tests. Which finding below during your assessment requires immediate nursing action?
A. The patient reports a headache.
B. The patient has a weak cough.
C. The patient has absent reflexes in the lower extremities.
D. The patient reports paresthesia in the upper extremities.
B. The patient has a weak cough.
A client who has experienced a myocardial infarction develops left ventricular heart failure. Which sign of poor organ perfusion should the nurse remain alert for?
a. Headache
b. Hypertension
c. Urine output of less than 30 mL/hr
d. Heart rate of 55 to 60 beats/min
c. Urine output of less than 30 mL/hr
Which of the following patients would not be a candidate for a hypotonic solution?
a. Patient with Diabetic Ketoacidosis
b. Patient with increased intracranial pressure
c. Patient experiencing Hyperosmolar Hyperglycemia
d. All of the options are correct
b. Patient with increased intracranial pressure
The nurse is evaluating the neurologic signs of a client in spinal shock following SCI. Which observation indicates that spinal shock persists?
a. Hyperreflexia
b. Positive reflexes
c. Flaccid paralysis
d. Reflex emptying of the bladder
c. Flaccid paralysis
Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Select all that apply.
a. Fluid volume overload
b. Renal insufficiency
c. Cerebral ischemia
d. Gastric stress ulcer
e. Pulmonary edema
b. Renal insufficiency
c. Cerebral ischemia
The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action?
a. Document the ICP reading in the chart.
b. Determine if the patient has a headache.
c. Assess the patient's level of consciousness.
d. Position the patient with the head elevated 60 degrees.
c. Assess the patient's level of consciousness.
Bonus: what is normal ICP, CPP, and MAP
A nurse is caring for a patient with an arteriovenous malformation (AVM). What symptom is the nurse most likely to observe in this patient?
a. Seizure
b. Headache
c. Intracranial pressure
d. Hemorrhage
d. Hemorrhage
A patient with chronic kidney disease (CKD) is started on hemodialysis, and after the first treatment, the patient complains of nausea and a headache. Prior to starting hemodialysis, the patient’s vitals were as following: HR 73, BP 134/67, RR 21, SpO2 99% RA, and temp 37. The nurse notes mild jerking and twitching of the patient's extremities. The second set of vitals read HR 99, BP 98/43, RR 32, SpO2 93% NC 3L, and temp 35.9. The nurse will anticipate the need to
a. Increase the time for the next dialysis to remove wastes more completely.
b. Switch to continuous renal replacement therapy (CRRT) to improve dialysis efficiency.
c. Administer medications to control these symptoms before the next dialysis.
d. Increase the rate for the next dialysis to increase the speed of solute removal.
b. Switch to continuous renal replacement therapy (CRRT) to improve dialysis efficiency.
A nurse educator is teaching a group of students about VAP. What statements shared by the students would indicate understanding of preventative measures for VAP? (SATA)
a. Maintain all head of beds at 20 degrees
b. Weaning protocol
c. Frequent repositioning
d. Frequent oral care
e. Avoidance of suctioning
b. Weaning protocol
c. Frequent repositioning
d. Frequent oral care
When caring for a patient in acute septic shock, what should the nurse anticipate?
a. Infusing large amounts of IV fluids
b. Administering osmotic and/or loop diuretics
c. Administering IV diphenhydramine (Benadryl)
d. Assisting with insertion of a ventricular assist device (VAD)
a. Infusing large amounts of IV fluids
A patient in the ER is admitted with the following complaints: inability to keep eyes open, extreme fatigue that is relieved with naps, and blurred double vision. These symptoms have progressed over several months, but have begun to interfere with the patient’s work and social life. Which of the following tests should you anticipate? SATA
a. CT brain
b. Blood draw (antibody testing)
c. Tensilon test
d. Echo
e. KUB
f. X-ray
b. Blood draw (antibody testing)
c. Tensilon test
Bonus: Which condition would be diagnosed with a positive Tensilon test?
Which of the following are indications for CRRT? SATA
a. Patient in ICU with acute renal failure
b. CKD patient who is non-ambulatory
c. CKD with hemodynamic instability
d. Patient’s who can handle a rapid rate of fluid removal
a. Patient in ICU with acute renal failure
c. CKD with hemodynamic instability
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
A. Ensure the client has adequate sedation.
B. Find another provider to intubate.
C. Interrupt the procedure to give oxygen.
D. Monitor the clients oxygen saturation.
C. Interrupt the procedure to give oxygen.
You're maintaining an EVD. The ICP readings should be?
a. 5 to 15 mmHg
b. 20 to 35 mmHg
c. 60 to 100 mmHg
d. 5 to 25 mmHg
a. 5 to 15 mmHg
Bonus: what are the indications for an external ventricular drain?
Which tests below can be ordered to help the physician diagnose Guillain-Barré Syndrome? Select all that apply:
A. Edrophonium Test
B. Sweat Test
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies
Which action should the nurse take to ensure accurate arterial line pressure readings?
a. Level the transducer to the level of the tip of the arterial catheter
b. Activate the fast-flush device before obtaining a pressure reading
c. Turn the stopcock off to the patient
d. Elevate the head of the bed for accurate readings
d. Elevate the head of the bed for accurate readings
The client is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the client to be lethargic, confused, and breathing rapidly. What is the nurse's priority response to the situation?
A) Stop the infusion and notify the physician because the client is in alkalosis.
B) Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis.
C) Continue the infusion, because the client is still in acidosis, and notify the physician.
D) Increase the rate of the infusion and continue to assess the client for symptoms of acidosis.
C) Continue the infusion, because the client is still in acidosis, and notify the physician.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?
A) Risk for impairment of tissue integrity caused by paralysis
B) Altered patterns of urinary elimination caused by quadriplegia
C) Altered family and individual coping caused by the extent of trauma
D) Ineffective airway clearance caused by high cervical spinal cord injury
D) Ineffective airway clearance caused by high cervical spinal cord injury
Match the term to the definition:
a. delirium
b. obtunded
c. somnolent
d. stuporous
1. A state of drowsiness or strong desire to fall asleep
2. Patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states
3. A mental state in which you are confused, disoriented, and not able to think or remember clearly.
4. An excessively deep state of unresponsiveness
Delirium: a mental state in which you are confused, disoriented, and not able to think or remember clearly.
Obtunded: patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.
Somnolent: a state of drowsiness or strong desire to fall asleep
Stuporous: an excessively deep state of unresponsiveness.