1. When monitoring cognitive function, the nurse should evaluate the clients
    orientation to time, place, person and ability to recall recent past events
  2. The nurse recognizes normal CSF as
    clear and colorless
  3. When the nurse is assessing muscle strength and movement its important to
    observe to see whether strength and movement are bilat equal and strong
  4. a pt in the ccu is being evaluated for brain disease, what test would determine brain death
  5. a pt is in the hospital with suspected intracerebral hemorrhage, the nurse knows that the pt will have which neuro test ordered
  6. a pt is brought into ED by the rescue squad. the pt was thrown from a vehicle. there was questionable consciousness on the way to the hospital. what neuro test does the nurse expect to see ordered
    xray of skull and spine and ct
  7. a pt is in the ED following a head injury, sign of risk of developing IICP is
    decreased LOC
  8. pt is hit by a swinging bat. this is an eg of
    an aceleration injury
  9. pt was riding in a car that hit a tree, the head hit the windshield the brain rebounded within the skull toward the opposite side
    acceleration-deceleration injury
  10. pt admitted with a CVA on admission VS were 120/80 client was awake, BP 150/90 pulse 52, L pupil slower than R
  11. Pt becomes unresponsive. L side of body is flaccid. Dr believes pt had CVA, what is the nurses priority intervention
    assess airway and breathing
  12. The nurse is caring for a pt with IICP, the nurse realizes a contraindication is
    suction the airway every hour per standing order
  13. pt with a spinal cord injury is recovering from spinal shock, the nurse realized that she should not develop a...full bladder because what emergent condition can occur if it is treated quickly
    autonomic dysflexia
  14. pt with spinal cord injury is recovering from a spinal cord injury has complete paralysis of the upper extremities and lower part of the body. what term describes this
  15. mr. jones is in intensive care following a MVA. he is oriented x3, movement in all extremeties and follows commands, VS stable, which findings indicate the earliest finding of Mr. Jones IICP is increasing
    orientation to person only
  16. nurse is caring for pt with sustained ICP of 18 mmHg past 30 min. Durng assessment of hygiene intervention what is the best nursing action
    provide rest period between interventions
  17. nurse is caring for a pt hit by a hammer. pt briefly lost consciousness but now conscious upon arrival at ED with CGS of 15, 1 hr later GCS of 5. what is the best nursing action
    notify DR immediately
  18. nurse assess a pt GCS score to be 3. What is the best interpretation by the nurse
    does not open eyes, no motor response, no verbal response
  19. nurse caring for pt with diminished LOC and MV. While performing suctioning, the pt lurches up and grasps catheter. what is the best interpretation by the nurse
    pt is exhibiting purposeful movement
  20. nurse admits pt to the ed with a new onset of slurred speech and R sided weakness, what is the priority nursing action
    determine time of symptom onset
  21. nurse admits pt to ed with a suspected cervical spine injury, what is the priority nursing action
    maintain proper head and neck alignment
  22. nurse is caring for pt 3 days following a coplete cervical spine injury. the pt is in spinal shock. following emergent intubation and ventilation, what is priority nursing action
    monitor BP
  23. nurse is caring for a pt admitted with hypovolemic shock. nurse palpates thready brachial pulse but is unable to auscultate a bp. what is the best nursing action
    assess bp by palpation or doppler
  24. pt is admitted to CCU following cabbage surgery, pulse 120 BP 70/50, pulmonary artery diastolic pressure is 2 mmHg. Lots of drainage through chest tube total 450 mL
    pt at risk for developing hypovolemic shock
  25. pt admitted after a marathon, she is lethargic, and decreased VS. nurse anticipates which therapeutc intervention
    hypertonic saline???
  26. nurse is caring for pt with severe sepsis. 105 degrees. RAP 1 mmHg. assume Dr orders. which intervention should nurse carry out first
    fluid challange?
  27. pt in ED at most risk for developing shock
    a pt with 2 days hx of NV and diarrhea
  28. HR 13bpm, resp 36, what is priority intervention
    epinephrine 1-3mL of solution IV
  29. during...shock what is the..efect of decrease cardiac output
    increased sympathetic stimulation
  30. while monitoring a pt for shock the nurse understands which system is the priority to tx
  31. pt 18 yo with possivle cervical injury. diminished vitals. pt skin is warm and flushed what is the best interpretation of the finding by the nurse
    pt is experienceing neurologic shock
  32. a nurse is admin a continuous infusion of recumbent human actuated protein C (Xigris) for septic shock. what is priority nursing
    assess for signs of bleeding
  33. pt admitted with elevated temp and general malaise, the nurse knows pt may have an infection. which lab value would be increased
  34. pt neutrophil level is 700cell/mL. the nurse is aware that she must adapt her care to focus on
    prevention of infections
  35. pt presents to the unti with an elevated temp and PNE. nurse knows that the pt lymphocyte count is extremely low. bc of this the nurse realizes that the pt has a decreased
    immune function
  36. which of the follwoing cells assist the body in blood clotting
  37. pt admitted with temp 103.4 and states that he has generalized body aches and night sweats. these are nonspecific symptoms of
    hyperthyroid disease?
  38. pt is to receive one unit of plateletys to txt thrombocytopenia, his plateley count is 75000 mL after his transfusion, the nurse will expect his count to me
  39. pt with cytolthrombo platetelet of 20000mL is to get multiple transfusions of platelets; the nurse notified the Dr that the pt has a history of febrile reactions with transfusion. the nurse expects
    benadryl given before transfusion
  40. comparing the various tx for DIC, which would be chosed to inhibit thrombin formation
    synthetic antithrombin III
  41. platelet count of less than 100,000mL is termed
  42. most numerous granulocytes are the
  43. pt hematrocrit is 33% and is noted to have significant orthostatic hypotension. nurse anticipates that the physcician will order
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