NSG 4100 EXAM 4 QUESTIONS AND ANSWERS A+
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Which of the following is indicative of worsening condition?
Pupil size changing from 5 to 9mm
(sign of increased ICP)
Which position is best best for patient who is at risk for increased ICP?
Semi Fowler position
Your patient is S/P craniotomy for tumor removal. Which of the following is
indicative of a complication?
Client states he feels a lot of drainage at the back of his throat
What is a normal reaction of a patient has received a craniotomy?
Eyes that are swollen post op
Your patient is S/P a craniotomy. Which of the following will need to reported to
the PCP?
BP change from 120/80 to 140/88
Which statement is correct about meningococcal vaccines #1 prevention?
Recommended between the ages 11-12 and boosters should be recv'd by age 16
Which is appropriate when caring for a patient with encephalitis?
Keeping room lights dim or off
You are caring for a patient who has had Huntington's for 15 years and is
admitted with pneumonia. Which actions is priority?
Set up bedside humidification
Your patient has been ordered pyridostigmine for myasthenia gravis. You
understand that this medication is used to?
Improve muscle strength
(DO NOT SKIP DOSES OF MEDICATIONS!)
Your patient is experiencing myasthenia exacerbation related to missed dose of
medication. Which are signs of this crisis state (SATA)
-Difficult speaking (Dysphonia)
-Extreme muscle weakness
-Shallow, slow RR
-Dyshpagia
,*Emergency Prepare for intubation
Your patient is diagnosed with Fibromyalgia. Which is a key feature of this
disease?
Difficulty Sleeping (insomnia)
What education statment is correct when teaching your patient with MS, about
activity and mobility?
Waking improves gait
Your patient sustained a C4 injury. You will expect all of the following EXCEPT?
Full range of motion
Autonomic dysreflexia is considered an emergency. Why?
Increase in BP can raise ICP
The patient with fibromyalgiai suffering from pain at 12 of the 18 identification site
sites, including the neck upper back and the knees. The patient also reports
nonfreshing sleep, depression, and being anxious when dealing with multiple
tasks. The nurse should teach the patient about what treatments? (SATA)
-Relaxation strategy (biofeedback)
-Serotonin reputake inhihibitor (e.g setraline)
-Establish a regular sleep patern
-Instruct patient on performing regular LOW IMPACT exercise such as walking,
swimming, biking and water exercise.
What medicaitons are approved for fibromyalgia pain?
Antidepressants (preglabalin & duloxetine) as these meds work to release serotonin and
nor-epinephrine in the brain
The nurse is caring for a client with a head injury and would recognize which
assessment findings as early sings of increase ICP? SATA
-Kussmaul breathing
-Weakness in one extremity
A nurse is caring for a client diagnosed to have a head injury. Which of the
following situations needs intervention by the nurse?
The client's spouse turns on the TV one hours in the afternoon and 3 hours in the
evening.
(You need low stimulation)
In a client with head injury ICP, _____________. External stimuli should be
________ to __________ oxygen consumption and prevent seizures.
1. increases 2. Reduced 3. Decrease
The critical care nurse is caring for a client with a head injury secondary to a
MVA. In the am the patient is responsive to painful stimuli and assumed
decorticate posturing. Two hours later which data would warrent immediate
intervention by the nurse?
The client extends the upper and lower extremities in response to painful stimuli
Extension of the upper and lower extremities is assuming a ___________ posture,
which indicated the client's intracranial pressure is ____________
1. Decerebrate 2. Increasing
, The nurse is caring for clients in the emergency department. Which client should
the nurse assess first?
The client with an epidural hematoma
An epidural hemtoma results from bleeding between the dura and inner surface
of the skull, and is an active ____________ bleed. This is a MEDICAL
EMERGENCY.
Arterial
A female patient has experienced an episode of myasthenic crisis. The nurse
would assess whether the patient is precipitating factors such as?
Omitting doses of medication
Myasthenic crisis often is caused by _____________-medication and responds to
the administration of cholinergic medications such as neostigmine and
____________
1. Over Under 2. Pyridostigmine
What is the treatment for Guillian Barre
Plasmapherisis
What is the treatment for Bacterial Meningitis?
Broad Spectrum Antibiotics
What is the treatment for Spinal Cord injury?
Methylprednisone
What is the treatment for Increased ICP?
Mannitol
What is the treatment for Neurogenic Shock?
Atropine Sulfate
What is the treatment for Autonomic Dysreflexia?
Hydralizine IV
What is the difference between Hospice and Pallative Care?
Hospice care occurs when the person has <6 m to live and may not be actively dying,
the goal is to allow for comfortability with no life-saving methods "Care NOT Cure"
Pallative care occurs when the person has >6m to live and may not be actively dying,
the goal is to improve quality of life by using holistic care; Gradual decline Chronic
illness (DM, Heart disease, dementia)
Describe the Sepsis bundle that should be completed within 3 hours?
1) Measure Lactate Level
2) Obtain Blood cultures
3) administration of broad spectrum ABX
4) Administer fluids 30 ml/kg crystalloid for hypotension or lactate >4
Describe the Sepsis bundle that should be completed within 6 hours?
5) Apply vasopressors (for hypotension that does not respond to fluids) Maintain MAP
>65 mm Hg
6) if lactate is >4 (36 mg/dl)
-measure CVP
-measure Scvo2
7) remeasure Lactate if initial lactate was elevated
A patient is diagnosed with hypovolemic shock. Which is a priority action?
GRADED. Buy Quality Materials!
Which of the following is indicative of worsening condition?
Pupil size changing from 5 to 9mm
(sign of increased ICP)
Which position is best best for patient who is at risk for increased ICP?
Semi Fowler position
Your patient is S/P craniotomy for tumor removal. Which of the following is
indicative of a complication?
Client states he feels a lot of drainage at the back of his throat
What is a normal reaction of a patient has received a craniotomy?
Eyes that are swollen post op
Your patient is S/P a craniotomy. Which of the following will need to reported to
the PCP?
BP change from 120/80 to 140/88
Which statement is correct about meningococcal vaccines #1 prevention?
Recommended between the ages 11-12 and boosters should be recv'd by age 16
Which is appropriate when caring for a patient with encephalitis?
Keeping room lights dim or off
You are caring for a patient who has had Huntington's for 15 years and is
admitted with pneumonia. Which actions is priority?
Set up bedside humidification
Your patient has been ordered pyridostigmine for myasthenia gravis. You
understand that this medication is used to?
Improve muscle strength
(DO NOT SKIP DOSES OF MEDICATIONS!)
Your patient is experiencing myasthenia exacerbation related to missed dose of
medication. Which are signs of this crisis state (SATA)
-Difficult speaking (Dysphonia)
-Extreme muscle weakness
-Shallow, slow RR
-Dyshpagia
,*Emergency Prepare for intubation
Your patient is diagnosed with Fibromyalgia. Which is a key feature of this
disease?
Difficulty Sleeping (insomnia)
What education statment is correct when teaching your patient with MS, about
activity and mobility?
Waking improves gait
Your patient sustained a C4 injury. You will expect all of the following EXCEPT?
Full range of motion
Autonomic dysreflexia is considered an emergency. Why?
Increase in BP can raise ICP
The patient with fibromyalgiai suffering from pain at 12 of the 18 identification site
sites, including the neck upper back and the knees. The patient also reports
nonfreshing sleep, depression, and being anxious when dealing with multiple
tasks. The nurse should teach the patient about what treatments? (SATA)
-Relaxation strategy (biofeedback)
-Serotonin reputake inhihibitor (e.g setraline)
-Establish a regular sleep patern
-Instruct patient on performing regular LOW IMPACT exercise such as walking,
swimming, biking and water exercise.
What medicaitons are approved for fibromyalgia pain?
Antidepressants (preglabalin & duloxetine) as these meds work to release serotonin and
nor-epinephrine in the brain
The nurse is caring for a client with a head injury and would recognize which
assessment findings as early sings of increase ICP? SATA
-Kussmaul breathing
-Weakness in one extremity
A nurse is caring for a client diagnosed to have a head injury. Which of the
following situations needs intervention by the nurse?
The client's spouse turns on the TV one hours in the afternoon and 3 hours in the
evening.
(You need low stimulation)
In a client with head injury ICP, _____________. External stimuli should be
________ to __________ oxygen consumption and prevent seizures.
1. increases 2. Reduced 3. Decrease
The critical care nurse is caring for a client with a head injury secondary to a
MVA. In the am the patient is responsive to painful stimuli and assumed
decorticate posturing. Two hours later which data would warrent immediate
intervention by the nurse?
The client extends the upper and lower extremities in response to painful stimuli
Extension of the upper and lower extremities is assuming a ___________ posture,
which indicated the client's intracranial pressure is ____________
1. Decerebrate 2. Increasing
, The nurse is caring for clients in the emergency department. Which client should
the nurse assess first?
The client with an epidural hematoma
An epidural hemtoma results from bleeding between the dura and inner surface
of the skull, and is an active ____________ bleed. This is a MEDICAL
EMERGENCY.
Arterial
A female patient has experienced an episode of myasthenic crisis. The nurse
would assess whether the patient is precipitating factors such as?
Omitting doses of medication
Myasthenic crisis often is caused by _____________-medication and responds to
the administration of cholinergic medications such as neostigmine and
____________
1. Over Under 2. Pyridostigmine
What is the treatment for Guillian Barre
Plasmapherisis
What is the treatment for Bacterial Meningitis?
Broad Spectrum Antibiotics
What is the treatment for Spinal Cord injury?
Methylprednisone
What is the treatment for Increased ICP?
Mannitol
What is the treatment for Neurogenic Shock?
Atropine Sulfate
What is the treatment for Autonomic Dysreflexia?
Hydralizine IV
What is the difference between Hospice and Pallative Care?
Hospice care occurs when the person has <6 m to live and may not be actively dying,
the goal is to allow for comfortability with no life-saving methods "Care NOT Cure"
Pallative care occurs when the person has >6m to live and may not be actively dying,
the goal is to improve quality of life by using holistic care; Gradual decline Chronic
illness (DM, Heart disease, dementia)
Describe the Sepsis bundle that should be completed within 3 hours?
1) Measure Lactate Level
2) Obtain Blood cultures
3) administration of broad spectrum ABX
4) Administer fluids 30 ml/kg crystalloid for hypotension or lactate >4
Describe the Sepsis bundle that should be completed within 6 hours?
5) Apply vasopressors (for hypotension that does not respond to fluids) Maintain MAP
>65 mm Hg
6) if lactate is >4 (36 mg/dl)
-measure CVP
-measure Scvo2
7) remeasure Lactate if initial lactate was elevated
A patient is diagnosed with hypovolemic shock. Which is a priority action?
