practice questions Flashcards
(39 cards)
What medication should a nurse anticipate giving a client with a temporoparietal fracture to reduce ICP?
Mannitol
If a client’s paCO2 level rises, what happens to the cerebral blood flow?
Dilates
What is an expected outcome of mannitol or furosemide administration in clients with increased ICP?
Increase urine output
What assessment indicates to a nurse that vasopressin intranasally is effective in a client diagnosed with DI?
Urinating 3-4 hours
What causes cerebral edema in a client with a serum sodium of 115 and decreased LOC?
Shift of fluid into intracellular space
What is an appropriate short term goal for a client admitted to the neurological ICU following a closed head injury?
ICP shouldn’t increase 15
What clinical manifestation is considered a neurological emergency after head trauma resulting in a temporal bone fracture?
Change in LOC
What is the best response for a nurse explaining the purpose of a drug-induced coma for a client with a severe head injury?
This med is used to decrease the activity of the brain so more damage doesn’t occur
What does it indicate if a nurse notes that the arms, wrists, and fingers are flexed, and the arms are adducted in a client with a head injury?
Decorticate
What should the nurse administer when preparing meperidine (Demerol) 100 mg for a client postop craniotomy who complains of pain of 7?
0.5 mL and another RN to witness the waste
Who has the highest priority for treatment among four victims of an automobile accident?
Sucking chest wound
What is the priority assessment for a client with a spinal cord injury at C3-4 in the ER?
Monitor respiratory effort and oxygen saturation level
Which client should the nurse assess first after receiving the change of shift report on the rehab unit?
C6 spinal cord who is complaining of dyspnea and has crackles in his lungs
What occurs immediately after a complete spinal cord injury regarding bowel and bladder function?
NG tube usually inserted to decompress the stomach
What should a nurse do first for a client with a complete cervical spine injury who has an extreme headache and blood pressure of 190/100?
Look for kinked foley catheter and bowel impaction
What indicates the presence of spinal shock in a client with a cervical neck fracture at the C5 level?
Flaccid paralysis and lack of sensation below the level of injury
What manifestations indicate worsening condition in a client diagnosed with C4 cervical spine injury treated for respiratory insufficiency?
Reduced chest excursion, paCO2 of 55, and poor cough effort
What lab result would require immediate follow up by the nurse for a client admitted with a spinal cord injury receiving high dose methylprednisone therapy?
WBC of 20,000
What syndrome is expected when a client with spinal cord trauma has loss of motor function and temperature sensation below the level of the lesion?
Anterior cord
What is the most important intervention for a nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?
Ensure that the client has fluid intake of 3-5 L per day
What lab result suggests the possibility of SIADH in a client who has cancer and has gained 2 pounds in 24 hours?
Serum sodium of 120
What problems are consistent with the diagnosis of SVC syndrome in a 78-year-old client with lung cancer?
Periorbital swelling and ring stuck on the left hand
What should be recorded in the recommendations section of the SBAR form for a client with sodium of 120 and potassium of 4.8?
Change infusion IV line to saline lock
What intervention should the nurse anticipate for a client with SIADH and a serum sodium level of 125?
Administer fluid restriction of 1800 ml per day
