ATI MEDSURG 2 NUR 265/ DETAILED ANSWER KEY NEURO-SHOCK & BURNS PRACTICE

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? A. Dextrose 5% in water Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water could cause rapid shifts in serum levels of some substances. B. 0.9% sodium chloride Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride could cause rapid shifts in serum levels of some substances. C. Dextrose 10% in water Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% or 20% in water until the next container of TPN solution arrives. D. Lactated Ringer’s solution Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution could cause rapid shifts in serum levels of some substances. 2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. “You should decrease your caloric intake when abdominal pain is present.” Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase their caloric intake in order to maintain weight. B. “You should increase your daily intake of protein.” Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein. C. “You should increase fat intake when experiencing loose stools.” Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent stimulation of the pancreas and steatorrhea. D. “You should limit alcohol intake to 2-3 drinks per week.” Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation of the pancreas. 3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness Rationale: Violent headache is correct. The client who manifests ICP should display a violent headache Neck pain and stiffness is incorrect. The client who manifests ICP should not display neck pain and stiffness Slurred speech is correct. The client who manifests ICP may display slurred speech. Projectile vomiting is correct. The client who manifests ICP may display sudden onset of projectile vomiting. Rapid loss of consciousness is correct. The client who manifests ICP may display a sudden rapid loss of consciousness. 4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe headache Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation. B. Bradycardia Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not bradycardia. C. Increased muscle tone Rationale: The nurse should find as a sign of meningococcal meningitis decreased not increased muscle tone. D. Oriented to time, person, place Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not