ICP/TBI/CVA
When the nurse applies a painful stimulus to the unconscious client, the client responds by stiffly extending and adducting the arms and hyperpronating the wrists. Which of the following does the nurse note in the client's record?
A. Decerebrate posturing
A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of systemic lupus erythematous?
A. Weight gain
B. Subnormal temperature
C. Elevated red blood cell count
D. Rash on the face across the bridge of the nose and on the cheeks
Answer:D
Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.
A client with a complete C4 spinal cord injury is admitted to the emergency department. Which of the following assessments is the highest priority for the nurse?
A. Assessing the client's deep tendon reflexes in the lower extremities.
B. Assessing the client's respiratory rate, effort, and oxygen saturation.
C. Assessing the client's level of consciousness using the Glasgow Coma Scale.
D. Assessing for the presence of bladder distention.
B
The phrenic nerve innervates the diaphragm and arises from C3-C5. An injury at C4 or above compromises diaphragmatic breathing, making respiratory failure the primary life-threatening emergency (ABCs).
A client with cirrhosis and massive ascites is scheduled for a paracentesis. Which of the following nursing actions is most critical immediately prior to the procedure?
A. Instruct the client to empty their bladder
B. Place the client in a high-Fowler’s position in bed
C. Administer an enema to empty the lower bowel
D. Infuse 1 liter of 0.9% sodium chloride rapidly prior to drainage
A.
Having the client void immediately before a paracentesis reduces the risk of accidental bladder perforation with the paracentesis needle, as a full bladder can displace upward into the abdominal cavity.
A nurse is providing discharge instructions to a client with systemic lupus erythematosus (SLE) who has a new prescription for hydroxychloroquine. Which instruction is most critical for the nurse to include in the client's teaching plan?
A. Schedule an annual dilated eye examination with an optometrist or ophthalmologist.
B. Take the medication on an empty stomach to enhance rapid absorption.
C. Expect mild yellowing of the skin and sclera as a harmless side effect.
D. Discontinue the medication immediately if your joint pain improves.
A
Long-term use of hydroxychloroquine can cause irreversible retinal toxicity and visual impairment. Regular ophthalmologic screenings (every 6 to 12 months) are essential for early detection of retinal damage.
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for a STAT computed tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consult.
C. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and
guide treatment.
A nurse is assessing a client newly diagnosed with rheumatoid arthritis (RA). Which clinical manifestation would the nurse expect to find during the initial physical assessment?
A. Symmetrical joint pain and morning stiffness lasting longer than 45 minutes.
B. Asymmetrical joint pain in weight-bearing joints that worsens with use.
C. Crepitus and bony hypertrophy limited strictly to the distal interphalangeal joints.
D. Sudden onset of severe hyperuricemia localized primarily to the great toe.
A
The nurse is differentiating between neurogenic shock and spinal shock in a newly admitted client with a thoracic spinal cord injury. Which clinical manifestation is uniquely characteristic of neurogenic shock?
A. Loss of all reflex activity below the level of the injury.
B. Flaccid paralysis of skeletal muscles.
C. Complete loss of sensation below the lesion.
D. Profound bradycardia and warm, dry extremities.
D.
Neurogenic shock results from the disruption of the sympathetic nervous system, leading to loss of vasomotor tone and peripheral vasodilation (hypotension, warm/dry skin) and unopposed parasympathetic tone (bradycardia).
While assessing a client with severe cirrhosis, the nurse instructs the client to hold their arms out with hands dorsiflexed. The nurse observes rapid, involuntary flapping movements of the hands. How should the nurse document this neurological finding?
A. Chorea
B. Asterixis
C. Myoclonus
D. Dystonia
B.
Asterixis, also known as "liver flap," is a classic sign of hepatic encephalopathy caused by the accumulation of ammonia in the central nervous system. It is elicited by having the client extend the arms and dorsiflex the wrists.
A client with portal hypertension is admitted to the emergency department with acute hematemesis from bleeding esophageal varices. Which of the following medications should the nurse anticipate administering first to reduce portal venous pressure?
A. Octreotide (Sandostatin)
B. Furosemide (Lasix)
C. Spironolactone (Aldactone)
D. Morphine sulfate
A.
Octreotide is a synthetic somatostatin analog that causes selective splanchnic vasoconstriction, significantly decreasing portal venous pressure and controlling acute variceal hemorrhage without causing severe systemic arterial vasoconstriction.
When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?
a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient's apical pulse is slightly irregular.
Correct Answer: B
Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.
A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory result or finding is most critical for the nurse to monitor during this therapy?
A. Serum sodium and potassium levels.
B. Fasting blood glucose levels.
C. Liver function tests and complete blood count (CBC).
A client with a T6 spinal cord injury reports a sudden, severe throbbing headache and nasal congestion. The nurse notes a blood pressure of 188/100 mmHg and a heart rate of 52 bpm. Which of the following findings is also expected?
A. Flushed, warm skin and profuse diaphoresis above the level of the injury.
B. Pale, cool, and dry skin over the entire body.
C. Tachycardia with an irregular heart rhythm.
D. Generalized body edema and petechiae.
A.
A client with cirrhosis is prescribed lactulose for hepatic encephalopathy. The nurse evaluates the medication as effective when observing which of the following outcomes?
A. Increase in systemic blood pressure
B. Decreased abdominal girth
C. Improvement in mental alertness and orientation
D. Normalization of serum transaminases (ALT/AST)
C.
A client with cirrhosis develops hepatic encephalopathy. The health care provider prescribes lactulose. What is the primary mechanism of action of this medication in this condition?
A. It binds to dietary proteins in the stomach to prevent their digestion.
B. It creates an acidic environment in the colon that converts ammonia to ammonium, which is then excreted.
C. It stimulates the regeneration of functional hepatic tissue.
D. It acts as an antibiotic to destroy urease-producing bowel bacteria.
B.
Lactulose acidifies the colon contents, converting absorbable ammonia (NH3) into non-absorbable ammonium (NH4+), which is eliminated in the stool.
A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 130/72, pulse 90, respirations 32
b. Blood pressure 148/78, pulse 112, respirations 28
c. Blood pressure 156/60, pulse 60, respirations 14
d. Blood pressure 110/70, pulse 120, respirations 30
Correct Answer: C
Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
An 11-month-old infant is evaluated for suspected cerebral palsy. Which finding would strongly indicate a neurological motor delay associated with CP?
A. Persistence of the Moro and asymmetric tonic neck reflexes
B. Sitting unsupported without difficulty for extended periods
C. Transferring small objects smoothly from hand to hand
D. Disappearance of the Babinski reflex
A.
After identifying that a client with a T4 spinal injury is experiencing autonomic dysreflexia, what is the nurse's immediate first action?
A. Administer the prescribed sublingual nifedipine.
B. Catheterize the client for a distended bladder.
C. Elevate the head of the bed to 45–90 degrees or sit the client upright.
D. Remove restrictive clothing and tight shoes.
C.
Correct! Raising the head of the bed lowers blood pressure via the orthostatic effect and helps reduce the risk of intracranial hemorrhage before searching for the noxious stimulus.
A nurse is caring for an adult client hospitalized with acute viral hepatitis A. Which of the following infection control precautions and room assignments is most appropriate?
A. Airborne precautions in a negative pressure isolation room
B. Standard precautions and contact precautions if the client is incontinent or has poor hygiene habits
C. Strict droplet isolation precautions with surgical masks worn by all visitors
D. Protective (reverse) isolation to prevent opportunistic infections
B.
Hepatitis A is transmitted via the fecal-oral route. Standard precautions are adequate for most continent, compliant adult patients, but contact precautions are added if the client has fecal incontinence, diaper use, or diaper-associated hygiene limitations.
A client taking high-dose prednisone for an acute flare of SLE tells the nurse, "I feel much better today, so I am going to stop taking these pills immediately." How should the nurse respond?
A. "Do not stop abruptly; the medication must be tapered slowly to allow your adrenal glands to recover function."
B. "That is fine as long as your joint pain has completely resolved for at least 24 hours."
C. "You can stop taking them immediately, but you must double your intake of vitamin C instead."
D. "Switching to an over-the-counter anti-inflammatory will safely replace the prednisone."
A.
Abrupt cessation of systemic corticosteroids can lead to acute adrenal insufficiency (adrenal crisis), which is life-threatening. The dose must be tapered gradually under provider supervision.
The critical care nurse provides care for a client who is admitted for the treatment of head trauma and prescribed mannitol to reduce intracranial pressure (ICP). Which electrolyte is the priority for the nurse to monitor?
Serum Sodium
A client experiencing an acute exacerbation of rheumatoid arthritis with painful, swollen joints asks about comfort measures. Which instruction should the nurse provide?
A. Apply moist heat packs to the actively inflamed joints for 30 minutes every hour.
B. Perform vigorous passive range-of-motion exercises during the acute flare-up.
C. Wear heavy splints continuously throughout the day and night without removal.
D. Apply cold packs to the acutely inflamed joints for 10 to 15 minutes to reduce pain and swelling.
D.
Cold application is recommended during acute flare-ups to vasoconstrict and decrease local inflammation and acute pain.
The nurse needs to reposition a client with an acute unstable thoracic spinal cord injury. Which technique is most appropriate for turning the client?
A. Use a draw sheet to pull the client across the bed independently.
B. Logroll the client as a single unit using at least three staff members while maintaining neutral spine alignment.
C. Flex the client's knees and hips gently before turning onto the side.
D. Elevate the head of the bed to 60 degrees prior to turning.
B.
Logrolling ensures that the head, neck, and torso move simultaneously as one solid block, preserving neutral spinal alignment and protecting the unstable column.
A nurse is monitoring a client who just underwent a therapeutic paracentesis with the removal of 6 liters of ascitic fluid. Which finding indicates an immediate post-procedure complication requiring rapid intervention?
A. A small amount of serosanguinous drainage on the dressing
B. A drop in blood pressure from 128/82 mmHg to 90/50 mmHg and tachycardia
C. Mild, localized tenderness at the needle insertion site
D. An increase in urine output from 20 mL/hr to 50 mL/hr
B.
Rapid removal of large volumes of ascitic fluid can cause massive fluid shifts into the peritoneal space, leading to profound hypovolemia, hypotension, and shock (post-paracentesis circulatory dysfunction). This requires immediate IV volume expanders (like albumin) and provider notification.
A client started on methotrexate for refractory SLE joint symptoms calls the clinic reporting a low-grade fever, fatigue, and a sore throat. What is the nurse's priority action?
A. Instruct the client to withhold the medication and report immediately for evaluation of potential bone marrow suppression/infection.
B. Advise the client to take acetaminophen every 4 hours for the low-grade fever.
C. Reassure the client that these are normal, transient side effects that will resolve within a few weeks.
D. Tell the client to double their folic acid supplement dose to counteract these systemic symptoms.
A.
Fever and sore throat are early warning signs of leukopenia or severe bone marrow suppression caused by methotrexate. The drug must be withheld and the provider notified immediately.