Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

Which of the following findings in the patient who has
sustained a head injury indicate increasing intracranial pressure
(ICP)?
a) Widened pulse pressure
Additional signs of increasing ICP include increasing systolic blood
pressure, bradycardia, rapid respirations, and rapid rise in body
temperature.
b) Increased pulse
Bradycardia, slowing of the pulse, is an indication of increasing ICP in
the head-injured patient.
c) Decreased respirations
Rapid respiration is an indication of increasing ICP in the head-injured
patient.
d) Decreased body temperature
A rapid rise in body temperature is regarded as unfavorable because
hyperthermia may indicate brain stem damage, a poor prognostic sign.
by

1 Answer

Answer :

a) Widened pulse pressure
Additional signs of increasing ICP include increasing systolic blood
pressure, bradycardia, rapid respirations, and rapid rise in body
temperature.
by

Related questions

Later signs of increased intracranial pressure (ICP) later include which of the following? a) Projectile vomiting Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

Description : Later signs of increased intracranial pressure (ICP) later include which of the following? a) Projectile vomiting Projectile vomiting may occur with increased pressure on the reflex center in the ... , the pulse pressure (the difference between the systolic and the diastolic pressure) widens.

Last Answer : a) Projectile vomiting Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Which of the following statements about head injury and concomitant hyponatremia are true? A. There are no primary alterations in cardiovascular signs. B. Signs of increased intracranial pressure may be masked by the hyponatremia. C. Oliguric renal failure is an unlikely complication. D. Rapid correction of the hyponatremia may prevent central pontine injury. E. This patient is best treated by restriction of water intake.

Description : Which of the following statements about head injury and concomitant hyponatremia are true? A. There are no primary alterations in cardiovascular signs. B. Signs of increased intracranial pressure may be ... central pontine injury. E. This patient is best treated by restriction of water intake.

Last Answer : Answer: A DISCUSSION: Acute symptomatic hyponatremia is characterized by central nervous system signs of increased intracranial pressure. Changes in blood pressure and pulse are secondary to ... lead to central pontine myelinolysis. Oliguric renal failure may rapidly develop in severe hyponatremia

Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a) 140, 90 According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140–159 or a diastolic pressure of 90–99.

Description : Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a) ... , 70 Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult.

Last Answer : a) 140, 90 According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140–159 or a diastolic pressure of 90–99.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion that will increase ICP.

Description : Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous ... an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Last Answer : a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion that will increase ICP.

Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Description : Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or ... for short periods of time. Difficulty in waking the patient should be reported or treated immediately.

Last Answer : a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? a) Progressive In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. b) Refractory The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the patient does not respond to treatment and cannot survive.

Description : Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? a) Progressive In the progressive stage of ... which organ damage is so severe that the patient does not respond to treatment and cannot survive.

Last Answer : a) Progressive In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

Description : An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics ... Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

Last Answer : a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless. b) Increased wakefulness As the body weakens, the patient will sleep more and begin to detach from the environment. c) Increased eating For many patients, refusal of food is an indication that they are ready to die. d) Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Description : For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the ... Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Last Answer : a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless.

Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Description : Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. ... rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

Last Answer : a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

An opening between the bladder and the vagina is called a a) vesicovaginal fistula. A vesicovaginal fistula may occur because of tissue injury sustained during surgery, vaginal delivery, or a disease process.

Description : An opening between the bladder and the vagina is called a a) vesicovaginal fistula. A vesicovaginal fistula may occur because of tissue injury sustained during surgery, vaginal delivery, or a disease ... d) rectovaginal fistula. A rectovaginal fistula is an opening between the rectum and the vagina.

Last Answer : a) vesicovaginal fistula. A vesicovaginal fistula may occur because of tissue injury sustained during surgery, vaginal delivery, or a disease process.

In studies of the human body, which of the following terms is used to describe a very rapid heart rate or pulse rate? Is it: a) bradycardia b) tachycardia c) cardiosis d) myocardia

Description : In studies of the human body, which of the following terms is used to describe a very rapid heart rate or pulse rate? Is it: a) bradycardia b) tachycardia c) cardiosis d) myocardia

Last Answer : ANSWER: B -- TACHYCARDIA

When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity. b) Vital capacity The nurse anticipates decreased vital capacity. c) Gas exchange and diffusing capacity The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. d) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration. b) 10-15 mm Hg water pressure. A measure of 10–15 mm Hg water pressure would indicate that the cuff is underinflated. c) 30-35 mm Hg water pressure. A measure of 30–35 mm Hg water pressure would indicate that the cuff is overinflated. d) 0-5 mm Hg water pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Description : Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the ... pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Last Answer : a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration.

Risk factors that increase the likelihood of post-traumatic seizures following a head injury include which of the following? a) Age over 65 years Risk factors that increase the likelihood of post-traumatic seizures following a head injury include brain contusion with subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more, and age over 65 years.

Description : Risk factors that increase the likelihood of post-traumatic seizures following a head injury include which of the following? a) Age over 65 years Risk factors that increase the likelihood of post ... is a risk factor that increases the likelihood of post-traumatic seizures following a head injury

Last Answer : a) Age over 65 years Risk factors that increase the likelihood of post-traumatic seizures following a head injury include brain contusion with subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more, and age over 65 years.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Diminished range of motion, loss of flexibility, stiffness, and loss of height are history and physical findings associated with agerelated changes of the a) joints. History and physical findings associated with age-related changes of the joints include diminished range of motion, loss of flexibility, stiffness, and loss of height.

Description : Diminished range of motion, loss of flexibility, stiffness, and loss of height are history and physical findings associated with agerelated changes of the a) joints. History and physical ... resolves with rest, crepitus, joint swelling/enlargement, and degenerative joint disease (osteoarthritis).

Last Answer : a) joints. History and physical findings associated with age-related changes of the joints include diminished range of motion, loss of flexibility, stiffness, and loss of height.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at a) controlling seizures and increased intracranical pressure. There is no specific medication for arboviral encephalitis. Medical management is aimed at controlling seizures and increased intracranial pressure.

Description : Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at a) controlling seizures and increased intracranical pressure. There is no specific medication for arboviral ... muscular atrophy. Medical management is aimed at controlling seizures and increased intracranial pressure.

Last Answer : a) controlling seizures and increased intracranical pressure. There is no specific medication for arboviral encephalitis. Medical management is aimed at controlling seizures and increased intracranial pressure.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Description : A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken ... headaches. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Last Answer : a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Of the following stimuli, which is known to trigger an episode of autonomic hyperreflexia in the patient who has suffered a spinal cord injury? a) Applying a blanket over the patient An object on the skin or skin pressure may precipitate an autonomic hyperreflexic episode.

Description : Of the following stimuli, which is known to trigger an episode of autonomic hyperreflexia in the patient who has suffered a spinal cord injury? a) Applying a blanket over the patient An ... lower blood pressure. d) Voiding The most common cause of autonomic hyperreflexia is a distended bladder.

Last Answer : a) Applying a blanket over the patient An object on the skin or skin pressure may precipitate an autonomic hyperreflexic episode.

According to the classification of hypertension diagnosed in the older adult, hypertension that can be attributed to an underlying cause is termed a) secondary. Secondary hypertension may be caused by a tumor of the adrenal gland (e.g., pheochromacytoma). b) primary. Primary hypertension has no known underlying cause. c) essential. Essential hypertension has no known underlying cause. d) isolated systolic. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

Description : According to the classification of hypertension diagnosed in the older adult, hypertension that can be attributed to an underlying cause is termed a) secondary. Secondary hypertension may be caused by a tumor of ... mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

Last Answer : a) secondary. Secondary hypertension may be caused by a tumor of the adrenal gland (e.g., pheochromacytoma).

Which of the following statement(s) is/are true concerning the treatment of MOFS? a. Prevention and therapy of MOFS requires control of the infectious or inflammatory source b. Restoration of normal clinical parameters such as blood pressure, pulse rate, and urine output ensures optimal resuscitation in most patients c. Branch chain amino acids play and important role in the nutritional support of the patient d. Because of the nature of gut injury, total parenteral nutrition is preferred for most patients with MOFS

Description : Which of the following statement(s) is/are true concerning the treatment of MOFS? a. Prevention and therapy of MOFS requires control of the infectious or inflammatory source b. Restoration of normal ... of the nature of gut injury, total parenteral nutrition is preferred for most patients with MOFS

Last Answer : Answer: a, c The therapy of MOFS is directed towards interrupting the involving pathophysiologic process and providing an optimal physiologic environment for healing and recovery. ... Enteral absorption and processing of nutrients appears superior to TPN and lessens overall complications

The intracranial pressure is decreased by: a. intravenous mannitol b. placing the patient in a head-up position c. hyperventilation d. all above

Description : The intracranial pressure is decreased by: a. intravenous mannitol b. placing the patient in a head-up position c. hyperventilation d. all above

Last Answer : all above

Morphine is contraindicated in head injury because (a) It does not relieve the pain of head injury (b) It can raise intracranial tension (c) It can cause constipation (d) It is liable to cause addiction

Description : Morphine is contraindicated in head injury because (a) It does not relieve the pain of head injury (b) It can raise intracranial tension (c) It can cause constipation (d) It is liable to cause addiction

Last Answer : Ans: B

Morphine is contraindicated in head injury because: A. It does not relieve the pain of head injury B. It can raise intracranial tension C. It can cause constipation D. It is liable to cause addiction

Description : Morphine is contraindicated in head injury because: A. It does not relieve the pain of head injury B. It can raise intracranial tension C. It can cause constipation D. It is liable to cause addiction

Last Answer : B. It can raise intracranial tension

The term given to the category of triage that refers to lifethreatening or potentially life-threatening injury or illness requiring immediate treatment is a) emergent. The patient triaged as emergent must be seen immediately.

Description : The term given to the category of triage that refers to lifethreatening or potentially life-threatening injury or illness requiring immediate treatment is a) emergent. The patient triaged as emergent ... . The triage category of immediate refers to non-acute, non-lifethreatening injury or illness.

Last Answer : a) emergent. The patient triaged as emergent must be seen immediately.

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to: a) decrease catabolism. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%.

Description : The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to: a) decrease catabolism. The most important intervention ... the energy source is seen after a burn injury; interventions are instituted to decrease catabolism.

Last Answer : a) decrease catabolism. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%.

When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

Description : When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a ... Injury from a flash flame is not associated with a burn that is limited to the epidermis.

Last Answer : a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. b) Neurogenic Neurogenic shock is associated with spinal cord injury and anesthesia. c) Cardiogenic Cardiogenic shock is associated with disease of the heart. d) Anaphylactic Anaphylactic shock is associated with hypersensitivity reactions.

Description : The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Septic Septic shock is associated with immunosuppression, extremes of age, ... disease of the heart. d) Anaphylactic Anaphylactic shock is associated with hypersensitivity reactions.

Last Answer : a) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures.

97. The nursing student reviews the laboratory findings and finds which blood results are elevated?

Description : 97. The nursing student reviews the laboratory findings and finds which blood results are elevated?

Last Answer : A. RBC, WBC, and platelets

Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Description : Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Last Answer : A. 1, 2, and 3

Mu opioids have which of the following effects on respiratory rate: a) Stimulation, then depression Mu opioids also cause bradycardia, hypothermia, and constipation. b) No change Kappa opioids result in no change in respiratory rate. c) Stimulation, only Delta opioids result in stimulation of respiratory rate. d) Depression, only Neither mu, nor kappa, nor delta opoids depress respiratory rate as its only effect upon respiratory rate.

Description : Mu opioids have which of the following effects on respiratory rate: a) Stimulation, then depression Mu opioids also cause bradycardia, hypothermia, and constipation. b) No change Kappa opioids result ... nor kappa, nor delta opoids depress respiratory rate as its only effect upon respiratory rate.

Last Answer : a) Stimulation, then depression Mu opioids also cause bradycardia, hypothermia, and constipation.

All of the following are true about neurogenic shock except: A. There is a decrease in systemic vascular resistance and an increase in venous capacitance. B. Tachycardia or bradycardia may be observed, along with hypotension. C. The use of an alpha agonist such as phenylephrine is the mainstay of treatment. D. Severe head injury, spinal cord injury, and high spinal anesthesia may all cause neurogenic shock.

Description : All of the following are true about neurogenic shock except: A. There is a decrease in systemic vascular resistance and an increase in venous capacitance. B. Tachycardia or bradycardia may be ... Severe head injury, spinal cord injury, and high spinal anesthesia may all cause neurogenic shock.

Last Answer : Answer: C DISCUSSION: Neurogenic shock occurs when severe head injury, spinal cord injury, or pharmacologic sympathetic blockade leads to sympathetic denervation and loss of vasomotor tone. ... of treatment. The use of alpha-adrenergic agonist is infrequently necessary to treat neurogenic shock

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

All of the following statements about hemorrhagic shock are true except: A. Following hemorrhagic shock, there is an initial interstitial fluid volume contraction. B. Dopamine, or a similar inotropic agent, should be given immediately for resuscitation from hemorrhagic shock, to increase cardiac output and improve oxygen delivery to hypoperfused tissues. C. The use of colloid solutions or hypertonic saline solutions is contraindicated for treatment of hemorrhagic shock. D. In hemorrhagic shock, a narrowed pulse pressure is commonly seen before a fall in systolic blood pressure.

Description : All of the following statements about hemorrhagic shock are true except: A. Following hemorrhagic shock, there is an initial interstitial fluid volume contraction. B. Dopamine, or a similar inotropic ... shock, a narrowed pulse pressure is commonly seen before a fall in systolic blood pressure.

Last Answer : Answer: BC DISCUSSION: Hemorrhagic shock is associated with a contraction of the interstitial fluid compartment because of precapillary vasoconstriction and reabsorption of interstitial fluid ... definitive evidence that such solutions are better than standard crystalloid solutions is lacking

Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

Description : Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs ... pain at the recipient site is anticipated since the wound has been protected by the graft.

Last Answer : a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of left-heart failure. b) Increased appetite Loss of appetite should be reported immediately. c) Weight loss Weight gain should be reported immediately. d) Ability to sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Description : The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of ... sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Last Answer : a) Persistent cough Persistent cough may indicate an onset of left-heart failure.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for redness and palpated for hardening. b) drainage. Drainage at the site does not indicate a reaction to the tubercle bacillus. c) tissue sloughing. Sloughing of tissue at the site of injection does not indicate a reaction to the tubercle bacillus. d) bruising. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Description : When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for ... site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Last Answer : a) redness and induration. The site is inspected for redness and palpated for hardening.

Premature ventricular contractions are considered precursors of ventricular tachycardia when they a) occur at a rate of more than six per minute. When PVCs occur at a rate of more than six per minute they indicate increasing ventricular irritability and are considered forerunners of ventricular tachycardia (VT). b) occur during the QRS complex. PVCs are dangerous when they occur on the T wave. c) have the same shape. PVCs are dangerous when they are multifocal (have different shapes). d) are paired with a normal beat. A PVC that is paired with a normal beat is termed bigeminy.

Description : Premature ventricular contractions are considered precursors of ventricular tachycardia when they a) occur at a rate of more than six per minute. When PVCs occur at a rate of more than six per minute they ... paired with a normal beat. A PVC that is paired with a normal beat is termed bigeminy.

Last Answer : a) occur at a rate of more than six per minute. When PVCs occur at a rate of more than six per minute they indicate increasing ventricular irritability and are considered forerunners of ventricular tachycardia (VT).

Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.

Description : Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid ... fluid requirements. d) Hypoglycemia Hypoglycemia is not associated with increased fluid requirements.

Last Answer : a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.