Nursing Care for Traumatic Brain Injury, Spinal Cord Injury, and Burn Victims, Exams of Nursing

Download Nursing Care for Traumatic Brain Injury, Spinal Cord Injury, and Burn Victims and more Exams Nursing in PDF only on Docsity! 1 TEST REVIEW EXAM 3 1. The nurse is working in the ED is admitting a client who has sustained a traumatic brain injury (TBI) following a motor vehicle crash. It is a priority for the nurse to notify the primary health care provider if the client? • Is unable to remember the crash • Takes prescribed warfarin daily (possible because of bleeding but not listed in the text, check lecture)* • Has a blood pressure of 162/94* • Reports having a continuous headache - The patient may have hypo or hypertension. Cushing's Triad, a classic but LATE sign of increased ICP, is manifested by severe hypertension, a widened pulse pressure (increasing difference between systolic and diastolic values), and bradycardia. This triad of cardio changes usually indicates imminent death. Pg945 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? • Setting up suction equipment bedside • Maintain client head at midline, neutral position • Using the bag valve mask on the client when the low pressure alarm sounds • Raising the foot of the clients bed 2 -Reverse Trendelenburg is acceptable, but raising feet above head would cause increased ICP pg 945 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 increased ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed? • Encouraging the clients visitors not to stimulate the client (T) 5 diagnosis? • Hand tremors • Constricted pupils that are nonreactive to light • Difficulty concentrating • A Glasgow coma scale score of 11 8. The nurse is providing discharge instructions to the partner of a client who sustained a mild head injury as a result of a motor vehicle crash. Which of the following statements by a partner indicates a correct understanding of the teaching • If my partner is sleeping, I will wake them up every 5-6 hours (F) • It is expected that my partner will have drainage from the nose for the next few days (F) • I will bring my partner to the emergency department (ED) immediately if they begin to vomit (T) • I will give my partner a lorazepam tonight to help with anxiety (F) 9. The nurse is caring for a client who is 24 hours postoperative following a craniotomy. The client is reporting a headache that is rated as an 8 on a 0 (no pain) to 10 (severe pain) pain scale. Which of the following actions should the nurse take? • Reposition the client supine with a pillow under the knees • Perform a neurological assessment • Place the client in a side lying position • Apply a heat pack to the back of the clients neck 10. • 6 • • • The nurse is caring for the following assigned clients. Which client should the nurse see first? The client who has a brain injury and is unable to remember the events surrounding the injury The client who has encephalitis and development of myoclonic jerking and tremors The client who has a skull fracture, is alert and oriented and reports feeling nauseated The client who has meningitis, is irritable and reporting a headache 7 11. The nurse is caring for a client who has encephalitis. It is important for the nurse to notify the PHCP if the client develops? • • • • 12. A headache (increased ICP) Increased sensitivity to noise Fatigue Decreased pulse rate The nurse working in the emergency department is caring for a client who presents with suspected bacterial meningitis. After performing a neurological assessment, which of the following actions should the nurse anticipate taking next? • Teaching the client about the condition and treatment • Placing the client in a negative pressure room • Preparing the client for a lumbar puncture • Administering an antiepileptic medication 13. The nurse is caring for a client who has confusion, fever, headache, blurred vision, nausea, vomiting, and a history of human immunodeficiency virus (HIV). The client is diagnosed with H. influenzae meningitis. Which of the following actions should the nurse take first? • Prepare the client for a computed tomography (CT) scan • Insert an intravenous (IV) catheter • Obtain a blood specimen for a CBC count • Initiate standard and droplet precautions 10 17. The nurse has taught a client who has myasthenia gravis about taking their prescribed medications on time and 45-60 minutes prior to meals. The client asks why the timing is so important. Which of the following is an appropriate response by the nurse? • Many foods interact with your medicine and this timing will allow them to absorb without causing problems • The medication needs to be taken on an empty stomach for maximum absorption and effect • This allows the medication to have maximum effect, so it is easier for you 11 • 18. to chew and swallow Many clients find it easier to remember to take their medications if they associate it with mealtimes The nurse working in the emergency department is caring for a client who has myasthenia gravis. The client presents with bladder incontinence, dysphagia, absence of cough, respirations of 40 with dyspnea, and generalized weakness. Which of the following actions should the nurse take immediately? • Administer atropine sulfate • Gather intubation equipment • Insert indwelling urethral catheter • Set up bedside suction 19. • • • • The nurse preceptor is observing a newly hired nurse care for a client who has myasthenia gravis. Which of the following actions by the newly hired nurse requires immediate intervention by the nurse preceptor? Monitoring the clients weight and prealbumin blood levels Preparing to administer a prescribed PRN laxative Coordinating physical therapy treatment during peak medication times Providing the client with a high calorie afternoon snack 20. • • 12 I will need to take corticosteroids for a week • • The nurse is teaching a client who was recently diagnosed with trigeminal neuralgia (tic douloureux). Which of the following statements by the client would indicate a need for further teaching? I may need to take a seizure medication for treatment I will tape my affected eye closed at bedtime I may notice the development of facial twitching I will need to use a soft toothbrush when brushing my teeth 21. • The nurse has provided teaching to a client who was just diagnosed with bells palsy. Which of the following client statements indicates a correct understanding of the teaching? 15 25. • • • • The nurse preceptor is observing a newly hired nurse care for a client who has GBS. Which of the following actions by the newly hired nurse requires intervention by the nurse preceptor? Assessing for dysphagia prior to eating a meal Having the client use the incentive spirometer Setting up bedside suction equipment Administering high flow oxygen via mask 26. • • • • 27. The nurse is using the rule of nine to calculate the extent of a male clients burn injury. The client has burns to the entire circumference of both legs and the genitalia. The nurse should document that the percent of total body surface area (TBSA) burned is 19% 28% 45% 37% The nurse is caring for a male client who sustained full thickness burns on the back and the posterior legs 6 hours ago. Which of the following laboratory values is an initial expected finding? • A white blood cell (WBC) count of 20,000 • A serum sodium level of 152 • A hematocrit level of 60% 16 • A blood glucose level of 64 28. The nurse is caring for a client who is burned and has developed drooling and difficulty swallowing. Which of the following actions should the nurse take first? • Auscultate breath sounds over the trachea and mainstem bronchi • Set up oxygen at the bedside for delivery via nasal cannula as needed • Have arterial blood gas ABG levels drawn on the client • Place the client on a continuous pulse oximeter monitor 17 29. • • • • The nurse is caring for a client who suffered burns to 33% total body surface area (TBSA) 48 hours ago. The nurse notes a gradual increase in the clients urine output over the last 12 hours. Which of the following actions should the nurse take? Report the findings to the primary health care provider Obtain an order to have the intravenous fluid rate decreased Gradually start increasing the clients oral fluid intake Document the findings and continue to monitor the output 30. • • • • The nurse is caring for a client who sustained an electrical injury and was brought to the emergency department (ED). After placing the client on a continuous cardiac monitor, which of the following nursing actions should the nurse take next? Apply sterile dressings to the wounds Initiate oxygen at 2 L via nasal cannula Assess the client for pain at contact points Check the clients potassium level 31. • • • • 20 • • • The nurse working on the burn step down unit has become aware of the following client situations. The nurse should initially follow up with the client who has? Refused to look at the wound during dressing changes An allergy to penicillin and has been prescribed the topical cream, gentamicin sulfate Increased burn wound drainage that has developed an odor Reported pain while performing active range of motion (ROM) exercises 36. The nurse is admitting a client who has sustained a thermal burn injury. The nurse notes the following assessment findings: 21 • • • • - 37. • • • • 38. • • • • 22 - Pul se rat e: 14 0 - Res pir ati on s: 25 - BP: 70/ 40 - Pal e ski n col or - Fai nt pe dal pul ses Which of the following actions should the nurse take first? Collect a STAT complete blood cell count (CBC) Check pedal pulses with a venous doppler device Obtain a 12 lead ECG Initiate prescribed intravenous (IV) fluid resuscitation Pg 489 resuscitation phase: immediate problems of fluid balance Initiate an IV line and begin fluid replacement The nurse is caring for a client who has circumferential full thickness burns to the left lower extremity. Which of the following findings of the affected extremity requires immediate follow up by the nurse? An increase in the skin temperature from cool to warm Numbness and tingling of the foot A change in skin color from pale to bright red An increase in the capillary refill from 2 to 3 seconds The nurse is caring for a client who was admitted 12 hours ago with severe burns. The client is receiving fluid resuscitation and weighs 175lbs (79.5 kg). Which assessment finding(s) from the box below is a priority for the nurse to report to the primary health care provided (PHCP)? -Urine output of 30mL/hr -Blood urea nitrogen (BUN) of 20mg/dL -Sodium level of 136 mEq/L -Potassium level of 6.2 mEq/L 25 T h e n u r s e is admitting a client diagnosed with septic shock. Which of the following interventions should the nurse perform first? Obtain central venous pressure (CVP) measurements Determine current blood glucose level Obtain 2 sets of blood cultures Administer IV vancomycin 42. • • • • The nurse is caring for a client who has a severe sepsis with septic shock. Which of the following prescriptions should the nurse question? Regular insulin intravenous (IV) infusion per protocol Cefazolin 1g intravenous (IV) every 6 hours Enoxaparin 40mg subcutaneous twice daily (no, use fractioned heparin) Transfusion of 2 units of fresh frozen plasma (FFP) 43. The nurse is caring for a client who has developed hypovolemic shock due 26 • • • • 44. to blood loss during surgery. The nurse should place the client in which of the following positions? HOB elevated Side lying with HOB elevated 15 degress Supine with head and feet flat HOB flat with the feet elevated (supine with feet elevated) The nurse is monitoring a client who is receiving a dopamine infusion for treatment of hypovolemic shock. Which of the following indicates a therapeutic response to the medication? • A blood pressure that has decreased from 150/92 to 130/88 • Urine output that has increased from 20 to 50 ml/hr (maintain organ perfusion) • A pulse rate that has increased from 62 to 78 • A decrease in mean arterial pressure (MAP) (f) 45. The nurse is caring for a client who has developed hypovolemic shock resulting from dehydration due to several days of vomiting and diarrhea. Which of the following actions should the nurse take next? • Initiate a 0.9% sodium chloride (NaCl) infusion (page 759 two common solutions are NS and RL) • Start dobutamine intravenous (IV) by continuous infusion • Insert an indwelling urethral catheter • Administer and antiemetic medication 46. 27 • • • • The nurse is caring for assigned clients. The nurse should recognize the development of obstructive shock in the client who? Has left sided heart failure (HF) resulting in pulmonary hypertension Sustained 60% total body surface area (TBSA) burns and has developed generalized edema Was admitted with an anaphylactic reaction to a newly prescribed antibiotic Is bleeding from the groin after accidently being shot with a nail gun -obstructive shock causes: cardiac tamponade, pulm htn (page 752 chart