1 You answered this question correctly. Time Spent: 66 Seconds 95% of people answered this question correctly. Last Updated: 12/30/2015 Test Id: 54335228 Question Id: 32076 (751847) The nurse is managing assigned clients on the evening shift. Which client presentation is a priority ? Unordered Options Ordered Response 1. Blunt head trauma with projectile vomiting 2. History of Alzheimer disease with agitation 3. History of carpal tunnel syndrome with hand numbness 4. History of third cranial nerve pathology with double vision Explanation A client with a traumatic head injury from blunt force can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. Signs and symptoms are similar to those of increased intracranial A A A 4 of 20 Leadership & Management Concepts Priority, Projectile Vomit 2 Leadership & Management Concepts DIC Priority pressure and include change in level of consciousness, projectile vomiting , ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated. (Option 2) Neuropsychiatric symptoms such as agitation, aggression, delusions, hallucinations, wandering, and depression are very common in clients with dementia. Some may have an underlying etiology (eg, pain, infection) that requires identification and treatment. This client is the second priority as the condition is not immediately life- threatening. (Option 3) Carpal tunnel syndrome is a compression of the medi an nerve within the carpal tunnel at the wrist. Clinical manifestations are weakness, pain, numbness, and impaired sensation in the median nerve distribution. Numbness is an expected symptom; a splint is worn to relieve the pressure. (Option 4) The third cranial nerve controls the majority (4/6) of the extraocular muscles. As a result, the lesion can cause weakness in eye movements with resultant diplopia, which is an expected finding. Educatio nal objective: A client with a head injury and signs of increased intracranial pressure (eg, change in level of consciousness, projectile vomiting, pupil dilation, ataxia) is a priority. Test Id: 54335228 Question Id: 34070 (751847) A A A 6 of 20 3 You answered this question correctly. Time Spent: 189 Seconds 69% of people answered this question correctly. Last Updated: 2/25/2016 The nurse is caring for clients on a busy medical -surgical unit. Which client would be priority to assess first? Unordered Options Ordered Response 1. A client with an ileostomy bag that has leaked stool all over 2. A client with chronic obstructive pulmonary disease, diminished breath sounds, and Sp O2 of 91% 3. A client with deep venous thrombosis who missed the last warfarin dose 4. A client with sepsis who is developing petechiae Explanation Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications . The initial cl otting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding ), signs of internal bleeding ( petechiae , ecchymosis, hematuri a, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death. (Option 1) Stool leaking from an ileostomy bag is not a priority. (Option 2) It is common for clients with chronic obstructive pulmonary disease to have diminished breath sounds; the goal SpO2 level in this population is generally ≥90%. 4 Postoperative Assessment - Prioritization (Option 3) Although missing warfarin can increase the risk of clotting, most clients will usually have a therapeutic INR for 1-2 days. This is not a priority over the DIC client. Educational objective: Disseminated intravascular coagulation (DIC) results from abnormal activation of clotting cascade followed by consumption of clotting factors and platelets; this quickly leads to life -threatening external and internal bleeding. Any signs of DIC should be assessed immediately as emergent replacement of clotting factors, blood, and platelets is needed to save the client. Test Id: 54335228 Question Id: 31099 (751847) A nurse receives the following change -of-shift morning report for the assigned clients. Which client should the nurse assess first? Unordered Options Ordered Response 1. Client 1 day postoperative with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning 2. Client 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F (38 C) 3. Client 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale 4. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours A A A 8 of 20
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