NURS 423 Exam 4 – 93 Questions with Correct and Verified answers. Graded A+

NURS 423 Exam 4 – 93 Questions with Correct and Verified answers. Graded A+ When caring for a patient who has admitted was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? 1. Continuous cardiac monitoring for bradycardia 2. Administration of methylprednisolone infusion 3. Assessment of respiratory rate and depth 4. Application of pneumatic compression devices to both legs - Correct answer 3. Assessment of respiratory rate and depth" "The nurses caring for a patient who sustained a spinal cord injury during administration of morning care the patient begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1. elevate the head of the bed 2. check the pmts urinary catheter for kinking 3. assess the pmts blood pressure 4. place the pt in the prone position - Correct answer 1. elevate the head of the bed" "A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings, its utmost concern to the nurse? 1. SpO2 of 92% 2. HR of 42bpm 3. BP of 112/70 4. Loss of motor and sensory function in the arms and legs - Correct answer 2. HR of 42bpm" "In assessing a patient with a teeth 12 spinal cord injury which clinical manifestations with the nurse expect to find to support the diagnosis of spinal shock? 1. Inability to move upper extremities 2. No reflex activity below the waist 3. Complaints of a pounding headache 4. Hypotension and bradycardia - Correct answer 2. No reflex activity below the waist" "A patient is being evaluated to rule out Myasthenia Gravis, and it's being administered the tensilon test. Which response to the test indicates the patient has Myasthenia gravis? 1. The pt has no apparent change in the assessment data 2. There is increased amplitude of electrical stimulation in the muscles 3. The circulating acetylcholine receptor antibodies are decreased 4. The pt shows a marked improvement of muscle strength - Correct answer 4. The pt shows a marked improvement of muscle strength" "The nurses caring for a patient who has been recently diagnosed with Myasthenia Gravis. The nurse should teach the patient that Myasthenia Gravis is caused by? 1. Amyloid plaques and neurofibrillary tangles 2. Destruction of acetylcholine receptors 3. Degeneration of dopamine-producing neurons in the basal ganglia 4. Demyelination of nerve fibers in the brain and spinal cord - Correct answer 2. Destruction of acetylcholine receptors" "When planning care for the patient with trigeminal neuralgia which patient outcome should the nurse set as the highest priority? 1. Maintenance of positive body image 2. Protection of the cornea 3. Relief of pain 4. Maintenance of nutrition - Correct answer 3. Relief of pain" "The nurse is performing an assessment on a patient with the diagnosis of Bell's palsy. The nurse should expect to observe which finding in the patient? 1. Periorbital edema 2. Facial drooping 3. Prosis of the eyelid 4. Twitching on the affected side of the face - Correct answer 2. Facial drooping" "A 24 year old pt is hospitalized with the onset of Guillain-Barre syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is? 1. Monitoring the cardiac rhythm continuously 2. Determining the level of consciousness every 2 hours 3. Evaluating sensation and strength of the extremities 4. Performing constant evaluation of respiratory function - Correct answer 4. Performing constant evaluation of respiratory function" "The patient diagnosed with Guillain-Barre syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? 1. You should make a full recovery within a few months to a year. 2. Most its with this syndrome have some type of residual disability. 3. This is something you should discuss with the healthcare team. 4. The rehab is short and you should be fully recovered within a month. - Correct answer 1. You should make a full recovery within a few months to a year." "Which assessment date would make the nurse suspect the patient has ALS? 1. History of a cold or vaccination within the last month 2. Complaints of double vision and drooping eyelids 3. Fatigue, progressive muscle weakness, twitching 4. Loss of sensation below the level of the umbilicus - Correct answer 3. Fatigue, progressive muscle weakness, twitching" "A 72 year old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium, rather than dementia? 1. The pt is disoriented to place and time but oriented to person 2. The pt has a hx of increasing confusion over several years 3. The pmts speech is fragmented and incoherent 4. The pt was oriented and alert when admitted - Correct answer 1. The pt is disoriented to place and time but oriented to person" "When teaching the spouse of a patient who is being evaluated for Alzheimer's disease, about the disorder, the nurse explains that: 1. The most important risk factor for AD is family history of the disorder 2. A diagnosis of AD can be made only when other causes of dementia have been ruled out 3. New drugs have been shown to reverse AD dramatically in some pts 4. The presence of brain atrophy detected by MRI confirms the diagnosis of AD in its with dementia - Correct answer 2. A diagnosis of AD can be made only when other causes of dementia have been ruled out" "When assessing a patient with Alzheimer's disease, who is being admitted to a long-term care facility. The nurse lines with the patient has had several episodes of wandering. Which nursing action will the nurse include in the plan? 1. Ask the patient why the wandering episodes have occurred 2. Reorient the pt to the new living situation several time daily 3. Place the patient in a room close to the nurse's station 4. Have the family bring in familiar items from the patient's home - Correct answer 3. Place the patient in a room close to the nurse's station" "A 78-kg patient with septic shock has a urine output of 30mL/hr for the past three hours. The pulse rate is 120 per minute and the central venous pressure is low. Which order by the healthcare provider will the nurse question? 1. Give PRN furosemide 40mg IV 2. Increase NS infusion to 250mL/hr 3. Administer hydrocortisone 100mg IV 4. Titrate norepinephrine to keep systolic BP 90mmHg - Correct answer 1. Give PRN furosemide 40mg IV" "A 19-year-old pt with massive trauma and possible spinal cord injury is admitted to the ED. Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? 1. Inspiratory crackles 2. Cool, clammy skin 3. Decreased HR 4. temp 99.9F - Correct answer 3. Decreased HR" "the ED nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimates arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain: 1. Hypothermia 2. LR 3. Two 14-gauge IV catheters 4. Dopamine infusion - Correct answer 3. Two 14-gauge IV catheters" "Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? 1. Hemoglobin is within normal limits 2. Urine output is 60mL over the last hour 3. Central venous pressure is normal 4. Mean arterial pressure is 72mmHg - Correct answer 2. Urine output is 60mL over the last hour" "A patient with septic shock has a BP of 70/46 mmHg, pulse 136, respirations 32, Temp is 104F and BG 46. Which intervention ordered by the health care provider should the nurse implement first? 1. Give NS IV at 500mL/hr 2. Give acetaminophen (Tylenol) 650mg rectally 3. Start insulin drip to maintain BG at 110 to 150mg/dL 4. Start norepinephrine to keep systolic BP 90mmHg - Correct answer 1. Give NS IV at 500mL/hr" "The nurse advises a patient with myasthenia gravis (MG) to: a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. ct the extremities from injury due to poor sensory perception. - Correct answer a. perform physically demanding activities early in the day." "A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures. - Correct answer a. Assist with active range of motion (ROM)." "Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness - Correct answer c. Respiratory effort" "Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patients bowel sounds. b. Notify the patients health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone). - Correct answer b. Notify the patients health care provider. * cholinergic crisis=atropine" "After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as like a band around my head c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinsons disease who has developed cogwheel rigidity of the arms - Correct answer a. Patient with myasthenia gravis who is reporting increased muscle weakness *myasthenic crisis" "A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patients speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years. - Correct answer a. The patient was oriented and alert when admitted." "Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration. - Correct answer b. Remind the patient frequently about being in the hospital." "When administering a mental status examination to a patient with delirium, the nurse should: a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination. - Correct answer c. choose a place without distracting stimuli." "The nurse is concerned about a postoperative patients risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation. - Correct answer d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation." "A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patients daily activities. d. Discuss the preventive use of acetylcholinesterase medications. - Correct answer b. Schedule the patient for more frequent appointments." "A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks. - Correct answer c. loss of recent and long-term memory." "Which action will help the nurse determine whether a new patients confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes. - Correct answer b. Use the Confusion Assessment Method tool." "A 72-year-old female patient is brought to the clinic by the patients spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patients current mental status, which question should the nurse ask the patient? a. Are you sad? b. How is your self-image? c. Where were you born? d. What did you eat for breakfast? - Correct answer d. What did you eat for breakfast?" "A patient is being evaluated for Alzheimers disease (AD). The nurse explains to the patients adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD. - Correct answer c. a diagnosis of AD is made only after other causes of dementia are ruled out." "Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patients family member administer the medication c. Posting reminders to take the medications in the patients house d. Calling the patient weekly with a reminder to take the medication - Correct answer b. Having the patients family member administer the medication" "A patient who has severe Alzheimers disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patients care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines. - Correct answer b. Maintain a consistent daily routine for the patients care." "A 71-year-old patient with Alzheimers disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses station. d. Ask the patient why the wandering episodes have occurred. - Correct answer c. Place the patient in a room close to the nurses station." "The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Keep blinds open during the daytime hours. b. Provide hourly orientation to time and place. c. Have the patient take a brief mid-morning nap. d. Move the patient to a quieter room late in the afternoon. - Correct answer a. Keep blinds open during the daytime hours." "The nurses initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patients room. - Correct answer c. assess for factors that might be causing discomfort." "When administering the Mini-Cog exam to a patient with possible Alzheimers disease, which action will the nurse take? a. Check the patients orientation to time and date. b. Obtain a list of the patients prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patients ability to recognize a common object such as a pen. - Correct answer c. Ask the person to use a clock drawing to indicate a specific time." "Which hospitalized patient will the nurse assign to the room closest to the nurses station? a. Patient with Alzheimers disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination - Correct answer c. Patient with new-onset confusion, restlessness, and irritability after surgery" "After change-of-shift report on the Alzheimers disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast - Correct answer d. Patient who developed a new cough after eating breakfast *aspiration" "After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimers disease, which topic will be most important for the nurse to discuss with the patient? a. Tobacco use b. Family history c. Head injury history d. Total cholesterol level - Correct answer a. Tobacco use *modifiable risk factor" "The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face. - Correct answer b. triggers leading to facial discomfort." "Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side. - Correct answer b. Inspect the oral mucosa and teeth." "When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will a. assess whether the patient is doing daily facial exercises. b. question whether the patient is using an eye shield at night. c. ask the patient about social activities with family and friends. d. remind the patient to chew on the unaffected side of the mouth. - Correct answer c. ask the patient about social activities with family and friends." "Which action will the nurse include in the plan of care for a 62-year-old patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient. - Correct answer a. Assess fluid and dietary intake." "The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bells palsy. Which information should the nurse include in teaching the patient? a. You may be able to prevent Bells palsy by doing facial exercises regularly. b. Prophylactic treatment of herpes with antiviral agents prevents Bells palsy. c. Medications to treat Bells palsy work only if started before paralysis onset. d. Call the doctor if you experience pain or develop herpes lesions near the ear. - Correct answer d. Call the doctor if you experience pain or develop herpes lesions near the ear." "A 32-year-old pregnant patient with Bells palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to a. respect the patients feelings and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patients concerns with visitors who arrive at mealtimes. - Correct answer a. respect the patients feelings and arrange for privacy at mealtimes." "Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts. - Correct answer c. Assist in planning a prescribed bowel program." "Which assessment data for a patient who has Guillain-Barr syndrome will require the nurses most immediate action? a. The patients triceps reflexes are absent. b. The patient is continuously drooling saliva. c. The patient complains of severe pain in the feet. d. The patients blood pressure (BP) is 150/82 mm Hg. - Correct answer b. The patient is continuously drooling saliva." "A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barr syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about a. intubation and mechanical ventilation. b. administration of corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. infusion of immunoglobulin (Sandoglobulin). - Correct answer d. infusion of immunoglobulin (Sandoglobulin)." "A construction worker arrives at an urgent care center with a deep puncture wound after an old nail penetrated his boot.. The patient reports having had a tetanus booster 6 years ago. The nurse will anticipate a. IV infusion of tetanus immune globulin (TIG). b. administration of the tetanus-diphtheria (Td) booster. c. intradermal injection of an immune globulin test dose. d. initiation of the tetanus-diphtheria immunization series. - Correct answer b. administration of the tetanus-diphtheria (Td) booster." "The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a. Hyperactive reflex activity below the level of injury b. Involuntary, spastic movements of the arms and legs c. Hypotension, bradycardia, and warm, pink extremities d. Lack of sensation or movement below the level of injury - Correct answer c. Hypotension, bradycardia, and warm, pink extremities" "A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Squard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patients left leg when turning the patient d. Teaching the patient to look at the right leg to verify its position - Correct answer c. Positioning the patients left leg when turning the patient" "The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury. - Correct answer b. function of both arms should be retained." "A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Cred method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours. - Correct answer b. Instruct the patient how to self-catheterize." "When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair. - Correct answer b. push a manual wheelchair on a flat surface." "A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse I want to be transferred to a hospital where the nurses know what they are doing! Which action by the nurse is best? a. Clarify that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patients comments. d. Reassure the patient about the competence of the nursing staff. - Correct answer b. Request that the patient provide input for the plan of care." "A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop because the patient is able to perform activities independently. c. develop a plan to increase the patients independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patients care and encourage that participation. - Correct answer c. develop a plan to increase the patients independence in consultation with the patient and the spouse." "A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by health care provider will the nurse question? a. Encourage oral fluids to 3 L/day b. Document neurologic symptoms c. Position patient lying on the side d. Observe respiratory status closely - Correct answer a. Encourage oral fluids to 3 L/day" "Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion - Correct answer b. Assessment of respiratory rate and effort" "A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The most essential assessment for the nurse to carry out is a. determining level of consciousness. b. checking strength of the extremities. c. observing respiratory rate and effort. d. monitoring the cardiac rate and rhythm. - Correct answer c. observing respiratory rate and effort." "Before administering botulinum antitoxin to a patient in the emergency department, it is most important for the nurse to a. obtain the patients temperature. b. administer an intradermal test dose. c. document the neurologic symptoms. d. ask the patient about an allergy to eggs. - Correct answer b. administer an intradermal test dose." "A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patients mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day. - Correct answer c. push upward on the epigastric area as the patient coughs." "A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, I have a pounding headache and I feel sick to my stomach. Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed analgesic. c. Assess the blood pressure (BP). d. Notify the health care provider. - Correct answer c. Assess the blood pressure (BP)." "A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, I feel hopeless. d. The patient expresses anxiety about having surgery. - Correct answer a. The patient has new onset weakness of both legs." "Which of these nursing actions for a 64-year-old patient with Guillain-Barr syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distention q2hr d. Passive range of motion to extremities q4hr - Correct answer d. Passive range of motion to extremities q4hr" "Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use? a. Avoid use of sedatives. b. Provide a quiet environment. c. Check pupil reaction to light every 4 hours. d. Provide range-of-motion exercises several times daily. - Correct answer b. Provide a quiet environment." "Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider? a. Back pain that increases with coughing b. Depression about the diagnosis of a tumor c. Decreasing sensation and ability to move the legs d. Anxiety about scheduled surgery to remove the tumor - Correct answer c. Decreasing sensation and ability to move the legs" "A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options. - Correct answer c. Multiple options are available to maintain sexuality after spinal cord injury." "When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blockers - Correct answer Urinary catheter care, Continuous cardiac monitoring, Maintain a warm room temperature, Administration of H2 receptor blockers" "A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question? a. Infuse normal saline at 250 mL/hr. b. Keep head of bed elevated to 30 degrees. c. Hold nitroprusside (Nipride) if systolic BP 90 mm Hg. d. Titrate dobutamine (Dobutrex) to keep systolic BP 90 mm Hg. - Correct answer a. Infuse normal saline at 250 mL/hr." "An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? a. Increase the rate for the dopamine (Intropin) infusion. b. Decrease the rate for the nitroglycerin (Tridil) infusion. c.Increase the rate for the sodium nitroprusside (Nipride) infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion. - Correct answer c.Increase the rate for the sodium nitroprusside (Nipride) infusion." "After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. nitroglycerine (Tridil) b. norepinephrine (Levophed) c. sodium nitroprusside (Nipride) d. methylprednisolone (Solu-Medrol) - Correct answer b. norepinephrine (Levophed)" "To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood. - Correct answer d. Check stools for occult blood. *stress ulcers" "A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% human albumin b. Furosemide (Lasix) IV c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef) - Correct answer b. Furosemide (Lasix) IV *reduces preload" "Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching. - Correct answer b. Monitor breath sounds frequently." "11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patients central venous pressure is 3 mm Hg. b. The patient is in sinus tachycardia at 120 beats/min. c. The patient is receiving low dose dopamine (Intropin). d. The patient has had no urine output since being admitted. - Correct answer a. The patients central venous pressure is 3 mm Hg. *normal is 2-6" "A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure 92/40 mm Hg - Correct answer c. Warm, pink, and dry skin" "Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation - Correct answer d. Oxygen saturation" "Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patients serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patients extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields. - Correct answer a. The patients serum creatinine level is elevated. *renal/heart failure" "When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock - Correct answer d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock *poikilothermia" "The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute - Correct answer b. Skin cool and clammy" "A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. obtain a 12-lead electrocardiogram (ECG). c. obtain the blood pressure. d. check the level of consciousness. - Correct answer a. administer oxygen. *ABCs" "During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities - Correct answer a. New onset of confusion *progressive stage of shock" "A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Initiate continuous electrocardiogram (ECG) monitoring. c. Provide oxygen at 100% per non-rebreather mask. d. Draw blood to type and crossmatch for transfusions. - Correct answer c. Provide oxygen at 100% per non-rebreather mask." "The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patients heart rate is 58 beats/minute. b. The patients extremities are warm and dry. c. The patients IV infusion site is cool and pale. d. The patients urine output is 28 mL over the last hour. - Correct answer c. The patients IV infusion site is cool and pale. *extravasation" "The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Start a normal saline infusion. b. Give epinephrine (Adrenalin). c. Start continuous ECG monitoring. d. Give diphenhydramine (Benadryl). - Correct answer b. Give epinephrine (Adrenalin)." "Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? a. The patients urine output is 18 mL/hr. b. The patients heart rate is 110 beats/minute. c. The patient is complaining of chest pain. d. The patients peripheral pulses are weak. - Correct answer c. The patient is complaining of chest pain. *potent vasoconstrictor" "After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg - Correct answer b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics" "After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate. - Correct answer c. Platelet count and presence of petechiae" "A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringers solution. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation. - Correct answer A, B, D, E" "Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. - Correct answer A, B, C, E"