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A client is admitted postcraniotomy. Decadron 4 mg IV is ordered every six
hours. The nurse understands the Decadron is ordered to
1. Incorrect prevent seizures.
2. Incorrect maintain the integrity of the gastric mucosa.
3. Correct decrease cerebral edema.
4. Incorrect stabilize the blood
sugar. Answer Rationale:
3. Cerebral edema is common after surgery. Decadron (a corticosteroid)
is given to decrease the edema.
Question 102 of
385 A client is admitted with a C7 complete transection. In the immediate
postinjury period, the nurse must plan for
1. Correct possible ventilatory support.
2. Incorrect bladder and bowel training.
3. Incorrect complications of autonomic dysreflexia.
4. Incorrect diaphragmatic
pacing. Answer Rationale:
1. Edema above the area of the lesion can cause respiratory depression and
arrest.
Question 103 of
385 A client fell backward over a stair rail to the floor below, and is not
breathing. After calling for assistance, how should the nurse proceed?
1. Incorrect After determining pulselessness, administer five
chest compressions at the rate of 60 per
minute.
2. Correct Initiate rescue breathing by performing a jaw thrust maneuver
and
administering two breaths.
3. Incorrect Initiate rescue breathing by performing a chin tilt
maneuver and administering two breaths.
4. Incorrect After determining absence of breathing, administer
15 chest compressions at the rate of 60 per minute.
Answer Rationale:
2. When initiating rescue breathing for a client with a suspected spinal
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injury, the jaw thrust maneuver is used with rescue breathing at the
rate of 12 breaths per minute.
Question 104 of
385 A client with a cervical spine injury was placed in Halo traction
yesterday. When the client complains of discomfort around the pins, what
action should the nurse take?
1. Incorrect Loosen the pins immediately and maintain the head in
a neutral position.
2. Correct Give the ordered analgesic and reassure the client that the pain
is
temporary.
3. Incorrect Carefully loosen the pins and notify the physician immediately.
4. Incorrect Cleanse the skin around the pin sites and dry the area
thoroughly. Answer Rationale:
2. Discomfort at the pin sites is expected for several days after application
of the Halo device. The pain can be controlled with mild analgesic
medication. The client can benefit from the reassurance that the pain
will not continue for the weeks that the traction will be in place.
Question 105 of
385 A client with a C6 spinal cord injury two months ago now complains of a
pounding headache. The pulse is 64 and the blood pressure is 220/110
mmHg. Which of the following actions should the nurse take first?
1. Incorrect Notify the physician.
2. Correct Elevate the client's head and lower the legs.
3. Incorrect Give the analgesic as ordered.
4. Incorrect Check for fecal
impaction. Answer Rationale:
2. The client is showing signs of autonomic dysreflexia. Placing the client
in a sitting position will allow blood to pool in the legs, which should
lower the blood pressure and prevent possible hypertensive
hemorrhage.
Question 106 of
385 The nurse is evaluating the ability of a client with trigeminal neuralgia to
implement the treatment that has been suggested. Which of the following
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behaviors by the client will be most effective in controlling manifestations?
The client
1. Incorrect puts the affected arm through full range of motion daily.
2. Incorrect uses proper body mechanics in sitting and bending.
3. Correct avoids extremes in temperature of food and drink.
4. Incorrect exercises the facial muscles at least
twice daily. Answer Rationale:
3. Extremes of temperature of food or drink can trigger paroxysms of
severe facial pain along the pathways of the trigeminal nerve. Meals are
better tolerated if served at room temperature.
Question 107 of
385 A client with Bell's palsy asks the nurse why artificial tears were ordered
by the physician. Select the best reply by the nurse.
1. Incorrect "Because your eye remains closed, foreign matter can be
trapped beneath the lid."
2. Incorrect "Artificial tears will remove the purulent drainage from
your eye, which speeds healing."
3. Correct "Because you cannot blink the affected eye, it can become dry
and irritated."
4. Incorrect "When your affected eye fails to make tears, the eye can
become irritated and ulcerated."
Answer Rationale:
3. Bell's palsy may cause paralysis of the eyelid and loss of the blink
reflex on the affected side. The eye may not close completely. These
problems render the eye susceptible to drying and irritation from dust
or other debris.
Question 108 of
385 A nurse is caring for a client with Guillain-Barré syndrome. Which of the
following strategies is of the most importance in the plan of care?
1. Incorrect Use of artificial tears.
2. Incorrect Starting an enteral feeding.
3. Correct Frequent measurement of vital capacity.
4. Incorrect Range of motion exercises three to four times
per day. Answer Rationale:
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3. Clients with Guillain-Barré have respiratory muscle weakness and
respiratory failure.
Question 109 of
385 The nurse has presented information about amyotrophic lateral sclerosis
(ALS) to a newly diagnosed client. Which question by the client indicates that
he understands the nature of the disease?
1. Incorrect "How can I avoid infecting my family with the virus?"
2. Incorrect "How can I prevent an exacerbation of the disease?"
3. Incorrect "How many people achieve remission with chemotherapy?"
4. Correct "How can I execute a living
will?" Answer Rationale:
4. Clients with ALS often experience respiratory failure as the disease
progresses, and need to communicate their wishes regarding ventilator
support. The nurse should explore the client's wishes and facilitate
discussion within the family. Arranging for the client to sign a living will,
if the client wishes to do so, is also a nursing responsibility.
Question 110 of
385 A client reports gradual painless blurring of vision. On assessment, the
nurse notes a
cloudy opaque lens. Based on this assessment, the nurse suspects the client has
1. Incorrect retinal detachment.
2. Correct cataracts.
3. Incorrect diabetic retinopathy.
4. Incorrect
glaucoma. Answer
Rationale:
2. These are the assessment findings of cataracts.
Question 111 of
385 Which of the following risk factors would the nurse assess for in a client
with glaucoma?
1. Correct Family history, increased intraocular pressure, and age of 45–
65.
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A client is admitted postcraniotomy. Decadron 4 mg IV is ordered every six
hours. The nurse understands the Decadron is ordered to
1. Incorrect prevent seizures.
2. Incorrect maintain the integrity of the gastric mucosa.
3. Correct decrease cerebral edema.
4. Incorrect stabilize the blood
sugar. Answer Rationale:
3. Cerebral edema is common after surgery. Decadron (a corticosteroid)
is given to decrease the edema.
Question 102 of
385 A client is admitted with a C7 complete transection. In the immediate
postinjury period, the nurse must plan for
1. Correct possible ventilatory support.
2. Incorrect bladder and bowel training.
3. Incorrect complications of autonomic dysreflexia.
4. Incorrect diaphragmatic
pacing. Answer Rationale:
1. Edema above the area of the lesion can cause respiratory depression and
arrest.
Question 103 of
385 A client fell backward over a stair rail to the floor below, and is not
breathing. After calling for assistance, how should the nurse proceed?
1. Incorrect After determining pulselessness, administer five
chest compressions at the rate of 60 per
minute.
2. Correct Initiate rescue breathing by performing a jaw thrust maneuver
and
administering two breaths.
3. Incorrect Initiate rescue breathing by performing a chin tilt
maneuver and administering two breaths.
4. Incorrect After determining absence of breathing, administer
15 chest compressions at the rate of 60 per minute.
Answer Rationale:
2. When initiating rescue breathing for a client with a suspected spinal
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,Nursing |Critical Care| Questions with Answers
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injury, the jaw thrust maneuver is used with rescue breathing at the
rate of 12 breaths per minute.
Question 104 of
385 A client with a cervical spine injury was placed in Halo traction
yesterday. When the client complains of discomfort around the pins, what
action should the nurse take?
1. Incorrect Loosen the pins immediately and maintain the head in
a neutral position.
2. Correct Give the ordered analgesic and reassure the client that the pain
is
temporary.
3. Incorrect Carefully loosen the pins and notify the physician immediately.
4. Incorrect Cleanse the skin around the pin sites and dry the area
thoroughly. Answer Rationale:
2. Discomfort at the pin sites is expected for several days after application
of the Halo device. The pain can be controlled with mild analgesic
medication. The client can benefit from the reassurance that the pain
will not continue for the weeks that the traction will be in place.
Question 105 of
385 A client with a C6 spinal cord injury two months ago now complains of a
pounding headache. The pulse is 64 and the blood pressure is 220/110
mmHg. Which of the following actions should the nurse take first?
1. Incorrect Notify the physician.
2. Correct Elevate the client's head and lower the legs.
3. Incorrect Give the analgesic as ordered.
4. Incorrect Check for fecal
impaction. Answer Rationale:
2. The client is showing signs of autonomic dysreflexia. Placing the client
in a sitting position will allow blood to pool in the legs, which should
lower the blood pressure and prevent possible hypertensive
hemorrhage.
Question 106 of
385 The nurse is evaluating the ability of a client with trigeminal neuralgia to
implement the treatment that has been suggested. Which of the following
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,Nursing |Critical Care| Questions with Answers
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behaviors by the client will be most effective in controlling manifestations?
The client
1. Incorrect puts the affected arm through full range of motion daily.
2. Incorrect uses proper body mechanics in sitting and bending.
3. Correct avoids extremes in temperature of food and drink.
4. Incorrect exercises the facial muscles at least
twice daily. Answer Rationale:
3. Extremes of temperature of food or drink can trigger paroxysms of
severe facial pain along the pathways of the trigeminal nerve. Meals are
better tolerated if served at room temperature.
Question 107 of
385 A client with Bell's palsy asks the nurse why artificial tears were ordered
by the physician. Select the best reply by the nurse.
1. Incorrect "Because your eye remains closed, foreign matter can be
trapped beneath the lid."
2. Incorrect "Artificial tears will remove the purulent drainage from
your eye, which speeds healing."
3. Correct "Because you cannot blink the affected eye, it can become dry
and irritated."
4. Incorrect "When your affected eye fails to make tears, the eye can
become irritated and ulcerated."
Answer Rationale:
3. Bell's palsy may cause paralysis of the eyelid and loss of the blink
reflex on the affected side. The eye may not close completely. These
problems render the eye susceptible to drying and irritation from dust
or other debris.
Question 108 of
385 A nurse is caring for a client with Guillain-Barré syndrome. Which of the
following strategies is of the most importance in the plan of care?
1. Incorrect Use of artificial tears.
2. Incorrect Starting an enteral feeding.
3. Correct Frequent measurement of vital capacity.
4. Incorrect Range of motion exercises three to four times
per day. Answer Rationale:
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3. Clients with Guillain-Barré have respiratory muscle weakness and
respiratory failure.
Question 109 of
385 The nurse has presented information about amyotrophic lateral sclerosis
(ALS) to a newly diagnosed client. Which question by the client indicates that
he understands the nature of the disease?
1. Incorrect "How can I avoid infecting my family with the virus?"
2. Incorrect "How can I prevent an exacerbation of the disease?"
3. Incorrect "How many people achieve remission with chemotherapy?"
4. Correct "How can I execute a living
will?" Answer Rationale:
4. Clients with ALS often experience respiratory failure as the disease
progresses, and need to communicate their wishes regarding ventilator
support. The nurse should explore the client's wishes and facilitate
discussion within the family. Arranging for the client to sign a living will,
if the client wishes to do so, is also a nursing responsibility.
Question 110 of
385 A client reports gradual painless blurring of vision. On assessment, the
nurse notes a
cloudy opaque lens. Based on this assessment, the nurse suspects the client has
1. Incorrect retinal detachment.
2. Correct cataracts.
3. Incorrect diabetic retinopathy.
4. Incorrect
glaucoma. Answer
Rationale:
2. These are the assessment findings of cataracts.
Question 111 of
385 Which of the following risk factors would the nurse assess for in a client
with glaucoma?
1. Correct Family history, increased intraocular pressure, and age of 45–
65.
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