Chapter 68 Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 13Th Edition

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Chapter 68  Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 13Th Edition

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

1. The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

  1. A)  Epistaxis
  2. B)  Periorbital edema
  3. C)  Bruising over the mastoid
  4. D)  Unilateral facial numbness

Ans: C

Feedback:

An area of ecchymosis (bruising) may be seen over the mastoid (Battle’s sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

2. A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 11⁄2 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?

  1. A)  Risk for impaired skin integrity
  2. B)  Risk for injury
  3. C)  Risk for autonomic dysreflexia
  4. D)  Risk for suffocation

Ans: B

Feedback:

If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient’s neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

3. A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

  1. A)  Respiratory distress and projectile vomiting
  2. B)  Bradycardia and hypertension
  3. C)  Tachycardia and agitation
  4. D)  Third-spacing and hyperthermia

Ans: B

Feedback:

Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (“goose bumps”), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

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4. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?

  1. A)  Hyperthermia
  2. B)  Tachycardia
  3. C)  Hypertension
  4. D)  Bradypnea

Ans: A

Feedback:

Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

5. A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was “knocked out,” but came to and “seemed okay.” Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

  1. A)  Insertion of an intracranial monitoring device
  2. B)  Treatment with antihypertensives
  3. C)  Emergency craniotomy
  4. D)  Administration of anticoagulant therapy

Ans: C

Feedback:

An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this patient.

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