Nursing Care for Traumatic Brain Injury, Septic Shock, and Burn Injuries, Exams of Nursing

Download Nursing Care for Traumatic Brain Injury, Septic Shock, and Burn Injuries and more Exams Nursing in PDF only on Docsity! 1 #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. 2 #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? 5 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. 6 #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% 7 #25: The nurse is caring for a male client who sustained full thickness burns on the back and posterior legs six hours ago. Which of the following lab values would be an initial expected finding? A serum sodium level of 128. RATIONALE: Pg. 1286. Imbalances include hyperkalemia and hyponatremia. #26: 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 first take? Auscultate breath sounds over the trachea and mainstream bronchi. RATIONALE: Pg. 1298. Upper airway edema and inhalation injury are most common in the trachea and mainstream bronchi. Auscultation of these areas may reveal wheezes, which indicate partial obstruction. #27: The nurse is caring for a client who sustained an electrical injury and was brought to the ED. Which of the following nursing actions should the nurse take first? Place the client on continuous cardiac monitoring RATIONALE: Pg. 1295. Electrical burns; obtain an ECG. #28: The nurse is caring for a client who suffered 33% TBSA 48hr ago. The nurse notes a gradual increase in the client’s urine output over the last 12 hrs. Which of the following actions would the nurse take? Document the findings and continue to monitor the output. RATIONALE: Pg. 1301. Urine output is decreased during the first 24 hr of the resuscitation phase. Monitor hourly output. #29: The nurse working in the ED is caring for a client with full thickness burns to 25% of the TSBA. After ensuring cardiopulmonary stability, which of the following actions should the nurse take next? Consult with the dietician regarding nutritional needs for the client. RATIONALE: Pg. 1326. Coordinate with the registered dietitian to meet the expected outcomes regarding the patient’s nutritional status. #30: The nurse working in the burn unit is caring for a client who suffered burn injuries 48 hrs ago and has been receiving resuscitation. The client has been stable but is now experiencing a change in respiratory status. Which of the following should the nurse correlate to this change in the client’s 10 #37: The nurse working the ED is assessing a client who presents with clinical manifestations of shock. Which of the following manifestations indicates that the client’s shock is caused by sepsis (infection)? Hypotension. RATIONALE: Pg. 1949. Septic shock is sepsis induced hypotension persisting despite adequate fluid resuscitation. #38: The nurse is caring for a client who is not responding to interventions for treatment of shock. Which of the following actions should the nurse include during this phase of the client’s care? Communicate clearly and frequently with the client’s family. RATIONALE: Pg. 1949. Even with appropriate intervention, the death rate among patients in this stage of sepsis is very high. 11 #39: The nurse is admitting a client diagnosed with septic shock. Which of the following interventions should the nurse perform next? Obtain 2 sets of blood cultures. RATIONALE: Pg. 1956. Obtain blood cultures before administering antibiotics. #40: The nurse is caring for a client who has severe septic shock. Which of the following prescriptions should the nurse question? Enoxaparin 40 mg subq BID. RATIONALE: Pg. 1957. Heparin therapy with fractionated heparin is used to limit inappropriate clotting and prevent the excessive consumption of clotting factors. #41: The nurse is caring for a client who has developed hypovolemic shock due to blood loss during surgery. The nurse should place the client in with of the following positions? HOB flat with the feet elevated. RATIONALE: Pg. 1940. Best practice for patient safety and quality care in the patient with hypovolemic shock. Elevate the patient’s feet, keeping the head flat or elevated no more than a 30 degree angle. #42: The nurse is monitoring a client who is receiving dopamine infusion for treatment of hypovolemic shock. Which of the following indicates a therapeutic response to the medication? A pulse rate that has increased from 62-78. RATIONALE: Pg. 1942. Common examples of drug therapy. Dopamine increases MAP, can cause decreased urinary output, hypertension (assess BP q15 min) HTN can indicate overdose. #43: The nurse is caring for a client who has developed hypovolemic shock resulting from dehydration due to several days of VD. Which of the following actions should the nurse take next? Initiate a 0.9% sodium chloride (NaCl) infusion. RATIONALE: Pg. 1941. Crystalloid fluids help maintain an adequate fluid electrolyte balance. Two common solutions are normal saline and Ringer’s lactate. #44: The nurse should recognize the development of obstructive shock in the client who: Has developed a large pericardial effusion resulting in cardiac tamponade. RATIONALE: Pg. 1925 (bottom): Obstructive shock cause and risk factors include cardiac tamponade. 12 #45: The nurse is caring for a client who is in cardiogenic shock and has been prescribed continuous infusion of norepinephrine. The nurse should recognize that the therapeutic effect of this medication: Increase the MAP RATIONALE: Davis drug guide. Therapeutic effects are increased BP and cardiac output. #46: The nurse is caring for a client who is in cardiogenic shock, was starting on a continuous infusion of an inotrope and has received a diuretic. It is a priority for the nurse to notify the PHCP if the client: 15 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 a. Checking the client's vital signs every hour 16 b. Clustering client care activities c. 20-yar-old college student who participates on the football team c. Instructing the client not to assist during repositioning d. Encouraging the client's visitors not to stimulate the client 4. The nurse is assessing clients for the risk of sustaining a TBI. Which of the following clients should the nurse identify as being at greatest risk? a. 45-year-old who has epilepsy and takes prescribed phenytoin b. 7-yar-old who is learning how to ride a bike without training wheels d. 60-yar-old who lives alone and wears a hearing aid 5. The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse to notify the PHCP? a. An output of 30 ml from the surgical drain of a client who had a craniotomy 6 hrs ago b. A report of tinnitus by a client who was recently diagnosed with an acoustic neuroma 17 c. The development of asymmetric pupils with no reaction to light in a client who has a TBI d. A decrease in the Glasgow coma scale score from 4 to 3 in a client who has a brain tumor 6. Then nurse us caring for a client who had a TBI with skull fracture. The nurse notes that the client has developed rhinorrhea that is positive for glucose. Which of the following actions should the nurse take next? 20 b. The client who has meningitis, is irritable, and reporting a HA following actions should the nurse take? a. Apply a heat pack to the back of the client's neck b. Place the client in a side-lying position c. Reposition the client supine with a pillow under the knees d. Perform a neurological assessment 10. The nurse is caring for the following assigned clients. Which client should the nurse see first? a. The client who has a skull fracture, is alert and oriented, and reports feeling nauseated c. The client who has encephalitis and development of myoclonic jerking and tremors d. The client who has a brain injury and unable to remember the events surrounding the injury 11. The nurse is caring for a client who has encephalitis. It is a priority for the nurse to notify the PHCP if the client develops 21 d. Decreased pulse rate a. A HA b. Fatigue c. Increased sensitivity to noise 22 a. Initiate standard and droplet precautions c. Preparing the client for a lumbar puncture 12. The nurse working in the ED is caring for a client who presents with suspected bacterial meningitis. After performing a neuro assessment, which of the following actions should the nurse anticipate taking next? a. Placing the client in a negative pressure room b. Teaching the client about the condition and treatment d. Admin an antiepileptic medication 13. The nurse is caring for a client who has confusion, fever, HA, blurred vision, nausea, vomiting, and a history of HIV. The client is diagnosed with H. influenzae meningitis. Which of the following actions should the nurse take first? b. Obtain a blood specimen for CBC count c. Insert an IV catheter 25 b. Limit visiting hours so the client can focus better on therapy activities c. Establish a plan of care with the client that sets attainable goals d. Obtain a prescription for a neurological consultation 26 immediately? a. Gather intubation equipment b. Set up bedside suction c. Admin atropine sulfate 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? a. Many clients find it easier to remember to take their medications if they associate it with mealtimes b. The medication needs to be taken on an empty stomach for max absorption and effect c. Many foods interact with your medications and this timing will allow them to absorb without causing problems swallow 18. The nurse working in the ED 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 d. This allows the medication to have max effect, so it is easier for you to chew and 27 myasthenia gravis. Which of the following actions by the newly hired nurse requires 30 and difficulty breathing a. What would you like done if you start to have trouble breathing b. Has GBS, developed paralysis form the neck to the toes, and was recently placed on mechanical ventilation? c. Was recently diagnosed with encephalitis, has ICP, and has decreased LOC d. Sustained a SCI is wearing a halo fixator device, and is experiencing depression since the injury 23. The nurse us discussing advance 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? b. Why are you afraid of being put on a breathing machine c. You could only be on the breathing machine for a short period of time d. You should discuss your wishes with your family and doctor a. Has had ALS for the past three years and was recently readmitted with pain, fatigue, 31 a. The immune system reacts by destroying the myelin sheath 24. The nurse has attended a continuing education conference about GBS. Which of the following statements by the nurse indicates a correct understanding of the conference? b. The distal nerves degenerate and results in muscle weakness c. Antibodies develop and attach to acetylcholine receptors d. Nerve impulses are not transmitted to the skeletal muscle 32 b. Admin high-flow oxygen via mask c. Setting up bedside suction equipment d. Having the client use the incentive spirometer a. 19% 25. The nurse preceptor is observing a newly hired nurses care for a client who GBS. Which of the following actions by the newly hired nurse requires intervention by the nurse preceptor? a. Assessing for dysphagia prior to eating a meal 26. The nurse is using the Rule of Nines to calculate the extent of a male client's 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 burned is b. 27% c. 45% d. 28% 27. *MISSED* 35 c. Initiate oxygen at 2 L via nasal cannula b. Apply sterile dressings to the wounds d. Check the client's potassium level 31. The nurse working in the ED is caring for a client with full-thickness burns to 25% of the total body surface. After ensuring cardiopulmonary stability and initiating IV fluids, which of the following actions should the nurse take next? a. Assess the client for musculoskeletal and mobility problems 36 b. This is due to prolonged exposure to carbon monoxide c. The client is having a panic attack and hyperventilating d. This is a delayed onset of respiratory complications due to fluid resuscitation 33. The nurse preceptor is observing a newly hired nurse who is caring for assigned clients in a. Applying an enzymatic debridement agent to black eschar tissue c. Consult with the dietitian regarding nutritional needs of the client d. Obtain a prescription for psychiatric consult to address image concerns 32. The nurse working in the burn unit is caring for a client who suffered burn injuries 48 hrs ago and has been receiving resuscitation. The client has been stable but is now experiencing a change in respiratory status. Which of the following should the nurse correlate to this change in the client's status? a. e client is staring to experience early signs of systemic infections a burn unit. Which of the following actions by the newly hired nurse indicates to the preceptor correct client care? b. Informing the client that a homograft is generally obtained from pig's skin b. Insert a NG tube to remove gastric sections 37 c. Admin a prescribed opioid analgesic by mouth 20 min prior to changing the client's dressing 40 d. Numbness and tingling of the foot 1. Urine output of 30 ml/hr 4. Potassium level of 6.2 6. Dyspnea with stridor d. Collet a STAT CBC 37. 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? a. An increase in skin temp form cool to warm b. A change in skin color form pale to bright red c. An increase in the cap refill from 2 to 3 sec 38. The nurse us caring for a client who was admitted 12 hrs ago with severe burns. The client is receiving fluid resuscitation and weighs 175 lbs (79.5 kg). Which assessment finding(s) from the box below is a priority for the nurse to report to the PHCP? 2. BUN of 20mg/dl 3. Sodium level of 136 5. 2+ peripheral edema 41 a. 3, 4, 5 b. 2, 3, 4, 6 42 d. 1, 4, 6 d. Temp of 96.4 F c. 1, 2, 3, 5 39. The nurse working in the ED is assessing a client who presents with a clinical manifestation of shock. Which of the following manifestations indicates that the client's shock is caused by sepsis? a. Anxiety and confusion b. Hypotension c. Pale clammy skin 40. The nurse is caring for a client who is not responding to intervention for treatment of shock and moving into the irreversible stage of shock. Which of the following actions should the nurse include during the phase of the client's care? a. Transfer the client to a subacute unite when recovery appears unlikely b. Begin to slowly reduce interventions as the prognosis worsens 45 d. Side-lying with HOB elevated 15 degrees 44. 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 46 c. Urine output that has increased from 20 to 50 ml/hr medication? a. A BP that has decreased from 150/92 to 130/88 b. A pulse rate that has increased from 62 to 78 d. A decreased in mean arterial pressure 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? a. Insert indwelling urethral cath b. Admin a antiemetic med c. Start dobutamine IV by continuous infusion d. Initiate a 0.9% sodium chloride (NaCl) infusion 46. The nurse is caring for assigned clients. The nurse should recognize the development of obstructive shock in the client who a. Sustained 60% total body surface burns and has developed generalized edema 47 b. Was admitted with an anaphylactic reaction to a newly prescribed antibiotic d. Is bleeding from the groin after accidently being shot with a nail gun 47. The nurse is caring for a client who is in cardiogenic shock and has prescribed a continuous infusion of norepinephrine. The nurse should recognize that the therapeutic effect of the medication is to c. Has left-sided heart failure resulting in pulmonary hypertension 50 being at risk for developing distributive shock? a. The client who was admitted with hemophilia and required a factor VIII infusion b. The client who was admitted 12 hrs ago with a SCI due to diving accident c. The client who developed ventricular fibrillation following a MI 50. The nurse is caring for assigned clients. Which of the clients should the nurse identify as d. 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