Love Again
The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first?
a. Document the presence of rhinorrhea.
b. Inform the physician of the assessment.
c. Assess the fluid for a halo sign.
d. Tape a drip pad under the nose.
ANS: C
Head injury symptoms may include rhinorrhea (fluid from the nose) or otorrhea (fluid from the ear), among many others. Rhinorrhea and otorrhea should be tested to determine if there is a cerebrospinal fluid (CSF) leak. Assessing for the halo sign on fluid from the nose or ear after a head injury. The blood will draw together in the middle of the gauze pad, leaving a yellow ring (halo) around the blood, indicating the presence of cerebrospinal fluid. Documentation, informing the physician, and applying a drip pad under the nose are actions that should occur after confirmation of the fluid type.
A nurse is caring for clients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered?
A. Level A
B. Level B
C. Level C
D. Level D
ANS: B
Rationale: Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection. Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical resistant gloves, and boots. Level D is the same as a work uniform.
Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse?
a. Intracranial bleeding
b. Encephalitis
c. Increasing intracranial pressure
d. Meningitis
ANS: D
Nuchal rigidity, skin rash, headache, and a positive Brudzinski sign are indicative of meningitis.
After a terrorist attack with smallpox virus, the nurse assesses a newly admitted patient with large vesicles. The nurse understands that which assessment finding differentiates smallpox vesicles from chickenpox vesicles?
a. Lesions on the face
b. Lesions on mucous membranes
c. Lesions on the soles of the feet
d. Lesions in the axilla
ANS: C
The lesions of smallpox can be found on the palms of the hands and soles of the feet. The lesions of chickenpox do not appear there.
The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease?
A. Intermittent hearing loss
B. Tinnitus
C. Tongue enlargement
D. Vocal paralysis
ANS: D
Rationale: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with this disease.
Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that what piece of equipment or clothing will be included?
A. A self-contained breathing apparatus
B. A vapor-tight, chemical-resistant suit
C. A uniform only
D. An air-purified respirator
ANS: D
Rationale: Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical-resistant gloves, and boots. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection, incorporating a vapor-tight, chemical-resistant suit and self-contained breathing apparatus (SCBA). Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection, incorporating a chemical-resistant suit and SCBA. Level D is the same as a work uniform.
The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness. The nurse most carefully monitors the patient for which change?
a. Increasing respiratory rate
b. Decreasing heart rate
c. Decreasing pulse pressure
d. Decreasing level of consciousness (LOC)
ANS: D
Assessment of LOC provides the greatest amount of information about neurologic condition. A reduction in LOC may signal the onset of complications in the patient who has had a head injury.
PTS: 1 DIF: Cognitive Level: Application REF: p. 515, Older Adult Care Points
OBJ: 2 (theory) TOP: Epidural Hematoma: Signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
A workplace explosion has left a 40-year-old client with full thickness burns over 75% of the body. Despite these injuries, the client is conscious. How would this person be triaged?
A. Green
B. Yellow
C. Red
D. Black
ANS: D
Rationale: The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The client would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery.
In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates that the patient will demonstrate which signs?
a. Left-sided hemiplegia with dilated right pupil
b. Right-sided hemiplegia with brisk right pupil response
c. Bilateral motor hemiplegia with bilaterally dilated pupils
d. Left-sided hemiplegia and bilateral PERRLA
ANS: A
An acute intracerebral bleed causing hematoma formation is accompanied by unconsciousness, hemiplegia on the contralateral (opposite) side, and a dilated pupil on the ipsilateral (same) side. However, the symptoms indicating a slow buildup of pressure within the skull are more subtle and less easily detected.
Following a craniotomy to relieve increased intracranial pressure (ICP), which implementation should the nurse implement?
a. Elevate the head of the bed 20 to 30 degrees.
b. Place drip pad or cotton to absorb cerebrospinal fluid (CSF) drainage from the nose or ears.
c. Stimulate the patient to better assess changing level of consciousness (LOC).
d. Reposition the patient frequently for comfort.
ANS: A
A patent airway must be secured, and the head raised 20 to 30 degrees with the body in correct alignment. Elevation helps reduce ICP. Neurologic signs are monitored closely. An IV line is inserted for access for diuretic drugs, if needed, and for administration of fluid. IV fluids are infused very slowly to prevent fluid overload that would increase the ICP. Diuretics are used to decrease vascular volume and keep ICP as low as possible. Drip pads, patient stimulation, and changing positions frequently may increase ICP.
The first responder to an automobile accident finds a victim with a sucking chest wound. What action should the responder take?
a. Tightly bind the injury with a folded magazine and the patient’s belt.
b. Place a plastic sandwich bag over the wound and tape on three sides to make a flutter dressing.
c. Turn the patient to the affected side and instruct the patient to deep breathe.
d. Place the patient’s hand over the wound and tell the patient to press down.
ANS: B
The flutter dressing will allow the air to leave the pleural space, but not allow any more air in. The collapsed lung will begin to re-expand.
The nurse is caring for a patient with flaccid paralysis after sustaining a spinal cord injury 3 days earlier. The family excitedly notifies the nurse that the patient has flexed his arm. Which response is best for the nurse to make?
a. “I will give the doctor this wonderful news.”
b. “Avoid directly touching the arm muscles so that you don’t cause more muscle spasms.”
c. “This movement means that the spinal cord is adjusting to the injury.”
d. “These muscles spasms are a type of involuntary movement that happens frequently in patients with spinal cord injuries.”
ANS: D
The patient is experiencing the spastic phases of paralysis that occurs as the cord adjusts to injury. The family members may interpret these spasms as a return of voluntary limb function and an indicator of impending complete recovery. First, the nurse should explain that this movement is not purposeful and an expected finding that often occurs in patients with spinal cord injuries. The nurse should not describe this finding as wonderful news. While it is important to avoid stimulating spasms, when moving the patient and the technique involves avoiding direct contact with the muscles, the family could misunderstand the nurse’s teaching as an accusation that someone’s touch caused this movement. While the spinal cord is adjusting to injury, this statement is vague enough that the family may not realize that the movement is not purposeful.
A nurse is triaging clients after a chemical leak at a nearby fertilizer factory. What is the guiding principle of this activity?
A. Assigning a high priority to the most critical injuries
B. Doing the greatest good for the greatest number of people
C. Allocating resources to the youngest and most critical
D. Allocating resources on a first-come, first-served basis
ANS: B
Rationale: In non-disaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. However, in a disaster, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. A first-come, first-served approach is unethical.
A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment?
A. Gag reflex
B. Deep tendon reflexes
C. Abdominal girth
D. Hearing acuity
ANS: A
Rationale: Preoperatively, the gag reflex and ability to swallow are evaluated. In clients with diminished gag response, care includes teaching the client to direct food and fluids toward the unaffected side, having the client sit upright to eat, offering a semisoft diet, and having suction readily available. Deep tendon reflexes, abdominal girth, and hearing acuity are less commonly affected by brain tumors and do not affect the risk for aspiration.
The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response?
A. "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."
B. "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible."
C. "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question."
D. "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."
ANS: A
Rationale: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The cell that produces myelin in the peripheral nervous system is the Schwann cell. In Guillain-Barré syndrome, the Schwann cell is spared, allowing for remyelination in the recovery phase of the disease. The nurse should avoid downplaying the client's concerns by wholly deferring to the health care provider.
A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client’s blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing?
A. Anaphylactic shock
B. Neurogenic shock
C. Septic shock
D. Hypovolemic shock
ANS: B
Rationale: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion?
A. The client is in the compensatory stage of shock.
B. The client is in the progressive stage of shock.
C. The client will stabilize and be released by tomorrow.
D. The client is in the irreversible stage of shock.
ANS: A
Rationale: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Clients display the often-described "fight or flight" response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the client's chance of survival is low and he will certainly not be released within 24 hours. If the client were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.
The nurse is caring for a patient with a spinal cord injury who develops autonomic dysreflexia (AD). Which action is most important for the nurse to take first?
a. Elevate the head of the bed.
b. Notify the charge nurse.
c. Decrease the IV fluid rate.
d. Administer antihypertensive medication.
ANS: A
AD (hyperreflexia) response is potentially dangerous to the patient, because it can produce vasoconstriction of the arterioles with an immediate elevation of blood pressure. Elevating the head of bed is the initial intervention to decrease the rising blood pressure. The nurse should notify the charge nurse and the physician. The IV fluids can be decreased but are not the most important intervention. The vital signs should be obtained and the cause of AD should be addressed before administering any hypertensive medication.
Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined?
A. A client with a blunt chest trauma with some difficulty breathing
B. A client with a sore neck who was immobilized in the field on a backboard with a cervical collar
C. A client with a possible fractured tibia with adequate pedal pulses
D. A client with an acute onset of confusion
ANS: A
Rationale: The client with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation are prioritized over other health problems, including skeletal injuries and changes in cognition.
A medical nurse is providing palliative care to a client with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care?
A. To improve the client's and family's quality of life
B. To support aggressive and innovative treatments for cure
C. To provide physical support for the client
D. To help the client develop a separate plan with each discipline of the health care team
ANS: A
Rationale: The goal of palliative care is to improve the client's and the family's quality of life. The support should include the client's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the client and family. The goal of palliative care is not aggressive support for curing the client. Providing physical support for the client is also not the goal of palliative care. Palliative care does not strive to achieve separate plans of care developed by the client with each discipline of the health care team.
A client is exhibiting late signs of increased intracranial pressure. Which finding would the nurse most likely assess? Select all that apply.
A. Hypertension
B. Bradycardia
C. Respiratory depression
D. Headache
E. Papilledema
ANS: A, B, C
Rationale: Late signs associated with rising ICP related to the vital signs are termed Cushing triad; those signs may include hypertension with a widening pulse pressure (the difference between systolic and diastolic pressure), bradycardia, and respiratory depression. Symptoms of rising ICP such as headache, nausea with or without vomiting, papilledema (edema of the optic disk), and visual changes occur earlier.
The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action?
A. Position the client the high Fowler position as tolerated.
B. Administer osmotic diuretics as prescribed.
C. Participate in interventions to increase cerebral perfusion pressure (CPP).
D. Prepare the client for craniotomy.
ANS: C
Rationale: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Clients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the client's condition.
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool?
A. Monro-Kellie hypothesis
B. Glasgow Coma scale
C. Cranial nerve function
D. Mental status examination
ANS: B
Rationale: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this client, but would not be the priority in evaluating LOC. Glasgow coma scale can be done quickly and establishes a baseline of neurologic function.
What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
A. Cushing syndrome
B. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Adrenal crisis
D. Diabetes insipidus
ANS: D
Rationale: Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the client becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (Select all that apply.)
a. An epidural hematoma is related to bleeding from arterial venous source.
b. An epidural hematoma can increase intracranial pressure (ICP) quickly.
c. An epidural hematoma changes overall condition quickly.
d. An epidural hematoma can cause death.
e. An epidural hematoma can cause irreversible brain damage.
ANS: B, C, D, E
An epidural hematoma can increase ICP quickly, changes overall condition quickly, and can cause death or irreversible brain damage. Bleeding is related to an arterial source. An epidural hematoma is a medical emergency.