Medsurg 2 Exam 1 Review Questions And Correct Verified Answers

MEDSURG 2 EXAM 1 REVIEW QUESTIONS
AND CORRECT VERIFIED ANSWERS
TheA2nurseA2isA2caringA2forA2aA2patientA2withA2increasedA2ICP.A2AsA2theA2pressureA2rises,A
2whatA2osmoticA2diureticA2doesA2theA2nurseA2prepareA2toA2administer?A2-A2Ans--Mannitol


TheA2nurseA2isA2caringA2forA2aA2clientA2inA2theA2ICUA2whoA2hasA2aA2brainA2stemA2herniatio
nA2andA2whoA2isA2exhibitingA2anA2alteredA2levelA2ofA2consciousness.A2MonitoringA2reveals
A2thatA2theA2client'sA2meanA2arterialA2pressureA2(MAP)A2isA260A2mmA2HgA2withA2anA2intracr
anialA2pressureA2(ICP)A2readingA2ofA25A2mmA2Hg.A2WhatA2isA2theA2nurse'sA2mostA2appropr
iateA2action?A2-A2Ans--
ParticipateA2inA2interventionsA2toA2increaseA2cerebralA2perfusionA2pressureA2(CPP).

TheA2nurseA2isA2participatingA2inA2theA2careA2ofA2aA2clientA2withA2increasedA2ICP.A2WhatA2
diagnosticA2testA2isA2contraindicatedA2inA2thisA2client'sA2treatment?A2-A2Ans--
LumbarA2puncture

TheA2nurseA2isA2caringA2forA2aA2clientA2whoA2isA2inA2statusA2epilepticus.A2WhatA2medicatio
nA2shouldA2theA2nurseA2anticipateA2administeringA2toA2haltA2theA2seizureA2immediately?A2-
A2Ans--IntravenousA2diazepam


TheA2nurseA2hasA2createdA2aA2planA2ofA2careA2forA2aA2clientA2whoA2isA2atA2riskA2forA2increa
sedA2ICP.A2TheA2client'sA2careA2planA2shouldA2specifyA2monitoringA2forA2whatA2earlyA2sign
A2ofA2increasedA2ICP?A2-A2Ans--DisorientationA2andA2restlessness


AA2clientA2hasA2experiencedA2aA2seizureA2inA2whichA2sheA2becameA2rigidA2andA2thenA2exp
eriencedA2alternatingA2muscleA2relaxationA2andA2contraction.A2WhatA2typeA2ofA2seizureA2d
oesA2theA2nurseA2recognize?A2-A2Ans--GeneralizedA2seizure

TheA2nurseA2isA2caringA2forA2aA2clientA2whoA2hasA2developedA2SIADH.A2WhatA2interventio
nA2isA2mostA2appropriate?A2-A2Ans--FluidA2restriction

AA2nurseA2isA2caringA2forA2aA2criticallyA2illA2clientA2withA2autonomicA2dysreflexia.A2WhatA2cli
nicalA2manifestationsA2wouldA2theA2nurseA2expectA2inA2thisA2client?A2-A2Ans--
BradycardiaA2andA2hypertension

TheA2nurseA2isA2caringA2forA2aA2clientA2withA2increasedA2intracranialA2pressureA2(ICP)A2ca
usedA2byA2aA2traumaticA2brainA2injury.A2WhichA2ofA2theA2followingA2clinicalA2manifestations
A2wouldA2suggestA2thatA2theA2clientA2mayA2beA2experiencingA2increasedA2brainA2compress
ionA2causingA2brainA2stemA2damage?A2-A2Ans--Hyperthermia


SignsA2ofA2increasingA2ICPA2includeA2slowingA2ofA2theA2heartA2rateA2(bradycardia),A2incre
asingA2systolicA2BP,A2andA2wideningA2pulseA2pressure.A2AsA2brainA2compressionA2increas
es,A2respirationsA2becomeA2rapid,A2BPA2mayA2decrease,A2andA2theA2pulseA2slowsA2further

, .A2AA2rapidA2riseA2inA2bodyA2temperatureA2isA2regardedA2asA2unfavorable.A2HyperthermiaA2
increasesA2theA2metabolicA2demandsA2ofA2theA2brainA2andA2mayA2indicateA2brainA2stemA2
damage.

TheA2staffA2educatorA2isA2preceptingA2aA2nurseA2newA2toA2theA2criticalA2careA2unitA2whenA2
aA2clientA2withA2aA2T2A2spinalA2cordA2injuryA2isA2admitted.A2TheA2clientA2isA2soonA2exhibitin
gA2manifestationsA2ofA2neurogenicA2shock.A2InA2additionA2toA2monitoringA2theA2clientA2clos
ely,A2whatA2wouldA2beA2theA2nurse'sA2mostA2appropriateA2action?A2-A2Ans--
PrepareA2forA2interventionsA2toA2increaseA2theA2client'sA2BP.

AA2clientA2whoA2hasA2sustainedA2aA2nondepressedA2skullA2fractureA2isA2admittedA2toA2theA
2acuteA2medicalA2unit.A2NursingA2careA2shouldA2includeA2whichA2ofA2theA2following?A2-
A2Ans--WatchfulA2waitingA2andA2closeA2monitoring


AA2clientA2whoA2sufferedA2aA2spinalA2cordA2injuryA2isA2experiencingA2anA2exaggeratedA2aut
onomicA2response.A2WhatA2aspectA2ofA2theA2client'sA2currentA2healthA2statusA2isA2mostA2li
kelyA2toA2haveA2precipitatedA2thisA2event?A2-A2Ans--
TheA2client'sA2urinaryA2catheterA2becameA2occluded.

AA2clientA2withA2aA2headA2injuryA2hasA2beenA2increasinglyA2agitatedA2andA2theA2nurseA2ha
sA2consequentlyA2identifiedA2aA2riskA2forA2injury.A2WhatA2isA2theA2nurse'sA2bestA2interventi
onA2forA2preventingA2injury?A2-A2Ans--PadA2theA2sideA2railsA2ofA2theA2client'sA2bed.


NarcoticsA2usedA2toA2controlA2restlessA2clientsA2shouldA2beA2avoidedA2becauseA2theseA2m
edicationsA2canA2depressA2respiration,A2constrictA2theA2pupils,A2andA2alterA2theA2client'sA2r
esponsiveness

AA2clientA2isA2admittedA2toA2theA2neurologicA2ICUA2withA2aA2spinalA2cordA2injury.A2WhenA2a
ssessingA2theA2clientA2theA2nurseA2notesA2thereA2isA2aA2suddenA2depressionA2ofA2reflexA2a
ctivityA2inA2theA2spinalA2cordA2belowA2theA2levelA2ofA2injury.A2WhatA2shouldA2theA2nurseA2su
spect?A2-A2Ans--SpinalA2shock

AA2nurseA2isA2reviewingA2theA2trendA2ofA2aA2client'sA2scoresA2onA2theA2GlasgowA2ComaA2S
caleA2(GCS).A2ThisA2providesA2whatA2potentialA2informationA2toA2theA2nurseA2aboutA2theA2
client'sA2status?A2-A2Ans--
AnA2assessmentA2ofA2theA2client'sA2currentA2levelA2ofA2consciousness

TheA2nurseA2isA2caringA2forA2aA2clientA2whoA2isA2rapidlyA2progressingA2towardA2brainA2deat
h.A2TheA2nurseA2shouldA2beA2awareA2ofA2whatA2cardinalA2sign(s)A2ofA2brainA2death?
A2SelectA2allA2thatA2apply.A2-A2Ans--Apnea
Coma
AbsenceA2ofA2brainA2stemA2reflexes