Nur 265 Literally Exam 3. (Answered) Complete Solution

Nur 265 Literally Exam 3. (Answered) Complete Solution #1: The nurse is working in the emergency department (ED) is admitting a client who has sustained a traumatic brain injury (TBI) following a motor vehicle crash. It is priority for the nurse to notify the primary healthcare provider (PHCP) in the client: Takes prescribed warfarin daily. RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment of impact. Warfarin is a blood thinner and the patient may bleed out if they have a hematoma (a collection of blood) #2: The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following actions, if performed by the newly hired nurse, requires intervention by the charge nurse? Raising the foot of the client’s bed. RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP. #3: The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed Clustering client care activities RATIONALE: pg. 2387. When multiple activities are clustered in a row, the effect on ICP can be dramatic elevation. #4: The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should the nurse identify as being at greatest risk? 20 year old college student who participates on the football team. RATIONALE: Pg. 2397. A force produce by a blow direct to the head can contribute to a brain injury. #5: The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse to notify the PHCP? The development of asymmetric pupils with no reaction to light in the client who has a TBI. RATIONALE: Pg. 2386. Pupillary changes; dilated and non reactive pupils “blown” or constrictive, non reactive pupils. #6: The nurse is caring for a client who had a TBI with skull fracture. The nurse noted that the client has developed rhinorrhea (nasal drip) that is positive for glucose. Which of the following actions should the nurse take next? Perform a halo sign test. RATIONALE: Pg. 2410. CSF leaking, lab test will be analyzed for glucose and electrolyte content. Place on a white absorbent paper or linen. #7: The nurse is providing discharge instructions to the partner of a client who sustained a mild head injury as a result of a MVA. Which of the following statements, if made by the partners would indicated the need for additional teaching? I will bring my partner to the ED if they immediately starting vomiting. RATIONALE: Pg. 2405. Symptoms usually resolve within 72 hrs. NV expected. #8: The nurse is caring for the following assigned clients. Which client should the nurse see first? The client who has a brain injury and a BP change from 110/58 to 134/40 mm Hg. RATIONALE: Pg. 2386. Cushing Triad. Severe HTN, widened pulse pressure, bradycardia. #9: The nurse is caring for a client who is 24 hours post op following a craniotomy. The client is reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which of the following actions should the nurse take? Perform a neurological test. RATIONALE: Pg. 2430. Symptoms of increased ICP included servers headache, deteriorating LOC, restlessness, and irritability. #10: The nurse is caring for a client who has encephalitis. It is priority for the nurse to follow up if the client Has a change in BP from 120/78 to 130/60 mm Hg. RATIONALE: Pg. 2256. Changes in VS that require immediate notification to the HCP are a widened pulse pressure, new bradycardia, and irregular respiratory effort. #11: The nurse is caring for a client who has been admitted with suspected bacterial meningitis. Which of the following actions should the nurse take first? Prepare the client for a lumbar puncture. RATIONALE: Pg. 2251. Most significant lab test to determine BM is testing of CSF with a lumbar puncture. A broad spectrum antibiotic is given before the lumbar puncture. #12: The nurse is caring for the client who has confusion, fever, headache, blurred vision, NV, and a history of HIV. Which of the following actions should the nurse take first? Implement seizure precautions. RATIONALE: This patient could have encephalitis due to the hx of HIV and fever. Seizure activity is common. #13: Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports blurred vision, BP 145/95, HR 68, O2 95%. Which of the following actions should the nurse take? Palpate the patient’s bladder. RATIONALE: Catheterize the patient with autonomic dysreflexia to decrease the pressure. This is an emergency. Immediately elevated the HOB. #14: The nurse working in the ED is caring for a client admitted with a suspected spinal cord injury. It would require follow up by the nurse if the PHCP prescribed which of the following? Mannitol. RATIONALE: Pg. 2291. Mannitol is used to treat ICP. Dextran, Atropine sulfate, and Dopamine are used to treat SCI. #15: The nurse has taught a client who has myasthenia gravis about taking their prescribed medications on time and 45-60 mins prior to meals. The client asks why timing is so important. Which of the following is an appropriate response by the nurse? This allows the medication to have maximum effect, so it is easier for you to chew and swallow. RATIONALE: Pg. 2344. Drug Alert! Eat 45-60 mins prior to avoid aspiration. #16: The nurse is working in the ED is caring for a client who has MG. The client presents with muscle weakness, NVD, and pulse of 58. Which of the following medications should the nurse admin immediately? Atropine sulfate. RATIONALE: Pg. 2345. In cholinergic crisis, admin Atropine I mg IV. #17: The nurse preceptor is observing a newly hired nurse care for a client who has MG. Which of the following actions by the newly hired nurse requires immediate intervention by the nurse preceptor? Preparing to admin a prescribed PRN laxative. RATIONALE: Pg. 2346. Perform tasks during peak medication times, monitor serum albumin levels, and provide high calorie snacks. #18: The nurse is teaching a client who has recently diagnosed with trigeminal neuralgia. Which of the following statements by the client would indicate need for further teaching? I will tape my affected eye closed at bedtime. RATIONALE: Pg. 2354. Seizure medication is first choice drug, facial twitching or spasms may occur, pain is usually provoked by minimal stimulation of a trigger zone (such as denture procedures.) Taping of the eye is not necessary for this patient. #19: The nurse is provided teaching to a client who was just diagnosed with Bell’s palsy. Which of the following client statements requires follow up by the nurse? I will need to take carbamazepine to control my symptoms. RATIONALE: Pg. 2255. This medication is used to treat TN. Patients will take steroids, use heat to control pain, and may experience ringing of the ears. #20: The nurse is caring for the following assigned clients. It would be appropriate for the nurse to recommend a referral for evaluation for palliative care for the client who Has had ALS for the past 3 years and was recently admitted with pain, fatigue, and difficulty breathing. RATIONALE: Pg. 2268. ALS is a chronic neurological disease that causes progressive muscle weakness and wasting, leading to paralysis of respiratory muscles. #21: The nurse is discussing advanced directives with a client who has ALS. The client tells the nurse “I don’t want to be put on a breathing machine.” Which of the following is an appropriate response by the nurse? What would you like to be done if you start to have difficulty breathing? RATIONALE: Involve the client in their care, ask what they’d like to happen. #22: The nurse has attended a CE conference on GB. Which of the following statements by the nurse indicates a correct understanding of the conference? The immune system reacts by destroying the myelin sheath. RATIONALE: Pg. 2329. Primarily the axons are affected. In other forms, demyelination typically begin in the legs and spread to the arms and upper body. #23: The nurse is assessing a client who has GB. The nurse notes diminished lung sounds, respirations of 8 and shallow, and a pulse ox of 88%. Which of the following actions should the nurse take? Prepare the client for intubation. RATIONALE: PG. 2334. The priority nursing intervention of airway management is to promote airway latency and adequate gas exchange. #24: The nurse is using the rule of 9s to calculate the extent of a clients burn injury. The client has burns to the posterior area of the torso, arms, and legs. The nurse should document that the percent of the body surface burned is: 45% 18 + 4.5 + 4.5 + 9 + 9 = 45 RATIONALE: Pg. 1302. Rule of 9s for estimating burn percentage. Head A&P: 4.5%, 4.5% Arms A&P: 4.5%, 4.5% Torso A&P: 18%, 18% Genitals: 1% Legs A&P: 9%, 9%