Critical Care Nursing 8th Edition Urden – Test Bank

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Chapter 05: Patient and Family Education

Urden: Critical Care Nursing, 8th Edition

 

MULTIPLE CHOICE

 

  1. A patient is scheduled for a cardiac catheterization this afternoon. The nurse wants to provide her with some basic information before going in the room to talk about her specific procedure. Which teaching strategy is most appropriate for this situation?
a. Discussion
b. Demonstration and practice
c. Audiovisual media
d. Written

 

 

ANS:  C

Media are used to educate patients on a variety of educational needs, such as medications, disease processes, procedures, symptom management, weight monitoring, laboratory tests, diet, surgery, and health maintenance issues. Patient education videos require the patient’s attention for only a few minutes and supply the learner with “nice-to-know” and “need-to-know” information. Demonstration and practice is not appropriate for this procedure because the patient is not performing the cardiac catheterization. Discussion and written material will help enhance the learning with the audiovisual media; however, this is not an interactive media.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 67

OBJ:   Nursing Process Step: Intervention   TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A nurse has been progressively working with a patient on the exercises he needs to do at home when he is discharged. The nurse wants to ensure he will remember what to do when he is at home. Which teaching strategy is most appropriate for this situation?
a. Discussion
b. Demonstration and practice
c. Audiovisual media
d. Written

 

 

ANS:  D

Written media, such as brochures, pamphlets, patient pathways, and booklets, are common in outpatient and inpatient areas of health care. Demonstration and practice would be useful throughout the hospitalization to make sure the patient is performing the exercises correctly. Discussion and audiovisual media would be appropriate in the assessment and intervention portion of learning; however, written material may be reviewed by the patient after returning home.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 68

OBJ:   Nursing Process Step: Intervention   TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What does the first step of the teaching–learning process involve?
a. Gathering data to assist in the assessment of learning needs
b. Identifying major learning needs for the patient
c. Identifying learning needs related to medical diagnosis
d. Evaluating the effects of prior teaching

 

 

ANS:  A

The first step of the teaching–learning process is assessment, which involves gathering a database to assist the nurse in meeting the patient’s and family’s needs. Learning needs can be defined as gaps between what the learner knows and what the learner needs to know, such as survival skills, coping skills, and ability to make care decisions.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 59

OBJ:   Nursing Process Step: N/A              TOP:   Patient and Family Education

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which educational content area is appropriate during the first hours of hospitalization?
a. Pathophysiology of the admitting diagnosis
b. Dietary modifications
c. Purpose of bedside equipment
d. Medication side effects

 

 

ANS:  C

Initial interventions are targeted to promote comfort and familiarity with the environment and surroundings. The plan should focus on survival skills, orientation to the environment and equipment, communication of prognosis, procedure explanations, and the immediate plan of care. Information regarding diagnosis, dietary modifications, and medication will be addressed after the patient is through the initial contact phase and is in the continuous care phase of education.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 72|Table 5-2

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. How should a nurse respond when a patient asks if he or she is going to die?
a. Avoid the question by leaving the room.
b. Defer the question to the physician.
c. Answer honestly and sensitively with information that is understandable and in simple terms.
d. Speak with the family first before answering the patient.

 

 

ANS:  C

During this time of elevated stress, the nurse may have to refocus the patient or family to help concentrate efforts on coping with the present instead of dwelling on possibilities of the future. Not addressing these immediate concerns could result in further anxiety, affect their ability to cope, and prevent open and honest communication.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 63|p. 65

OBJ:   Nursing Process Step: Intervention   TOP:   Patient and Family Education

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which intervention can support a learning environment in the critical care unit?
a. Providing a variety of caregivers to enhance the availability of different information
b. Allowing frequent uninterrupted rest periods to enhance obtaining structured sleep
c. Providing the patient lists of facts that can enhance understanding of the disease
d. Teaching according to a structured plan to enhance comprehension

 

 

ANS:  B

Sleep cycle alterations caused by sleep deprivation or sensory overload related to continuous noise from machines or people affect the patient’s ability to concentrate and comprehend information. Allowing frequent uninterrupted rest periods assists the patient in obtaining structured sleep. Assignment of multiple caregivers may negatively affect the ability of the patient and family to form a trusting relationship with the nursing staff. Teach whatever the patient wants to learn and avoid lists of facts.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 63|Table 5-1

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. A patient is admitted to the critical care unit with the onset of tuberculosis. He was diagnosed with HIV/AIDS 1 year ago. When talking to the patient about preventing the spread of tuberculosis, the patient tells the nurse that he has not followed precautions regarding tuberculosis for patients with HIV. Which educational objective is BEST stated for this patient?
a. Patient will know at least two ways to prevent the spread of tuberculosis within 1 week.
b. Patient will understand how HIV is spread within 3 days.
c. Patient will realize that improper precautions will spread his disease to others.
d. Patient will verbalize two methods of transmission for tuberculosis within 2 days.

 

 

ANS:  D

Terms such as know, understand, realize, and appreciate are open to many interpretations and are difficult to measure. Active verbs such as identify, state, list, and demonstrate should be used. The three components in the outcomes statement are (1) the individual who will meet the objective, (2) a measurable or observable verb, and (3) the content to be evaluated or learned.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 66

OBJ:   Nursing Process Step: Planning        TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When writing goals and outcomes, what should be incorporated in the outcome statement?
a. An action oriented intervention list
b. An observable verb
c. The objectives for the nurse
d. The length of the education session

 

 

ANS:  B

The three components in the outcomes statement are (1) the individual who will meet the objective, (2) a measurable or observable verb, and (3) the content to be evaluated or learned. When goals or expected outcomes of the education encounter are clearly stated, the teacher and the learner understand the expectations and will do their best to achieve them. These statements differ from interventions in that they reflect what the learner is to accomplish, not what the nurse is to teach. The length of the education session is not part of the outcome statement.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 66

OBJ:   Nursing Process Step: Planning        TOP:   Patient and Family Education

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. In which situation are group discussions most effective as a patient teaching strategy?
a. Patients have a variety of medical diagnoses.
b. Patients are in the acute phase of their illness.
c. Patients are in the hospital only 3 days or less.
d. Patients are at similar stages of adaptation.

 

 

ANS:  D

Hospitalized patients with similar problems and at similar stages of adaptation can benefit from discussion groups. The patient and each member of the family may be experiencing different stages in the adaptation process at the same time. The education encounter may need to be modified to meet the needs of the patient and family.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 63|Table 5-1

OBJ:   Nursing Process Step: Planning        TOP:   Patient and Family Education

MSC:  NCLEX: Psychosocial Integrity

 

  1. According to Maslow’s hierarchy of needs, the need to know and understand information is considered what type of need?
a. High-level
b. Low-level
c. Physiologic
d. Critical

 

 

ANS:  A

Experiencing the stress of a physiologic need requires immediate attention and is considered a lower level, immediate need. The need to know and understand is a high-level need and can only be met if no lower level needs require attention.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 61

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is asked to complete an admission form. The patient hands the form to his spouse and asks her to complete the form, stating, “I forgot my glasses.” What might be inferred from the patient’s actions?
a. Patient has functional health literacy.
b. Patient needs a word recognition test.
c. Patient has low health literacy.
d. Patient needs a reading comprehension test.

 

 

ANS:  C

Behaviors such as handing a form to a family member to complete, claiming to be too tired, or “forgetting” one’s glasses are a few behaviors that may be used by individuals to hide their limitations or low health literacy. Word recognition tests consist of lists of health care terms that patients are asked to read. Reading comprehension tests assess understanding of health care information presented but do not demonstrate the individual’s ability to apply this information. Functional health literacy tests assess the individual’s level of comprehension and ability to put into action what he or she has learned.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 61|pp. 64-65|Box 5-2

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Psychosocial Integrity

 

  1. What are the three learning domains to be considered when developing an individualized education plan?
a. Knowledge, ability, and willingness to learn
b. Psychologic, skills, and knowledge
c. Knowledge, skills, and attitude
d. Skills, attitude, and psychologic

 

 

ANS:  C

Three learning domains are considered when developing an individualized education plan: knowledge, attitude, and skills.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 65

OBJ:   Nursing Process Step: N/A              TOP:   Patient and Family Education

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. Information on what topic should be included in the educational plan of a patient who is unconscious?
a. Sensations
b. Pathophysiology
c. Rehabilitation
d. Attitudes

 

 

ANS:  A

Providing information regarding environment, procedures, sensations, and time of day is benevolent and may help decrease immediate physiologic stress.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 70

OBJ:   Nursing Process Step: Intervention   TOP:   Patient and Family Education

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. What topic should be included in the education of a patient’s family members during their first visit?
a. When to call the practitioner
b. Availability of support groups
c. Expectations about self-care
d. What the patient may look like

 

 

ANS:  D

The focus of the any education during the first visit should include what the patient may look like. When to call the practitioner, availability of support groups, and expectation for self-care should be included into later teaching sessions.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 64|Table 5-2

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient has been in the critical care unit for 20 days with a diagnosis of sepsis and acute respiratory distress syndrome. The patient is ready for transfer to the step-down unit but is apprehensive. The patient has communicated to the nurse that he does not want to leave the ICU because he is afraid that his needs will not be met on the step-down unit. Which educational objective would be best to use in this situation?
a. The patient will state two reasons why he is being transferred by the end of the day.
b. The patient will confront his fears and deal with them within 1 day of transfer.
c. The patient will state the name of his “new” nurse by the end of the day.
d. The patient will be introduced to at least two of his “new” caregivers by the time of transfer.

 

 

ANS:  D

The patient needs to trust the new caregivers on the step-down unit. Introducing the new caregivers will help decrease his anxiety about an unfamiliar environment. Objectives must be realistic in expectation and timeline. Anxiety and fear of change will decrease the patient’s cognitive level.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 64|Table 5-2

OBJ:   Nursing Process Step: Planning        TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A 79-year-old patient received a liver transplant 3 days ago. The patient is extubated and hemodynamically stable. His spouse is coming for a visit, and the nurse has some time to discuss immune suppression drug therapy with both of them. The patient is hearing and sight impaired. The spouse brought the patient’s hearing aids 2 days ago and will bring the patient’s glasses today. Which of the following teaching strategies would be least effective in the critical care unit setting?
a. Patient education channel
b. Written materials
c. Lecture
d. Discussion

 

 

ANS:  C

Lecture is not the strategy of choice for this situation; it does not work well in the critical care unit. Teaching must be done at the bedside by using as many of the senses as possible. Written material, discussion, demonstration, and use of media are common teaching strategies used in the critical care unit.

 

PTS:   1                    DIF:    Cognitive Level: Evaluating             REF:   p. 60

OBJ:   Nursing Process Step: Intervention   TOP:   Patient and Family Education

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. During which phase do Health Insurance Portability and Accountability Act (HIPAA), advance directives, and visitation policies occur for the patient or family members?
a. Transfer to a different level of care
b. End-of-life care
c. Initial contact or first visit
d. Continuous care

 

 

ANS:  C

During preparation for the first visit, the nurse would instruct the patient or family on Health Insurance Portability and Accountability Act (HIPAA), advance directives, and visitation policy. Transfer to a different level of care includes orientation to the receiving unit. Continuous care includes discussion of day-to-day routines, procedures, and treatment process. End-of-life care includes discussion of palliative care or hospice.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 64|Table 5-2

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. Which of the following statements best describes the teaching–learning process?
a. It follows the distinct order of the nursing process, with each step of the process separate and without repetition.
b. It requires formal blocks of learning time that are planned during the shift.
c. It is a continuous activity that occurs during hospitalization and beyond.
d. It ends at the point of discharge.

 

 

ANS:  C

In the teaching–learning process, the steps of the nursing process (assessment, diagnosis, goals, interventions, and evaluation) may occur simultaneously and repetitively. The teaching–learning process is a dynamic, continuous activity that occurs throughout the entire hospitalization and may continue after the patient has been discharged.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 59

OBJ:   Nursing Process Step: N/A              TOP:   Patient and Family Education

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which statement best describes the efficacy of group discussion as a patient teaching strategy for educating both a patient newly diagnosed with diabetes and a patient who has had the disease for years?
a. It is an efficient use of the nurse’s time.
b. It is an efficient use of the patient’s time.
c. It is an effective strategy as both patients have identical goals.
d. It is not an appropriate teaching strategy.

 

 

ANS:  D

Educational needs between the two patients will differ. Group discussion is only effective when the goals of the education plan are the same for all patients involved. A patient newly diagnosed with diabetes will require education on topics that are potentially well known to a patient diagnosed years ago.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 63

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A mechanically ventilated patient is being weaned off sedation. The patient begins to wake up and becomes increasingly agitated, pulling at the gown, kicking, and grimacing. What action should the nurse take next?
a. Administer additional sedation until the patient stops kicking
b. Initiate wrist restraints to prevent the patient from pulling
c. Tell the patient to stop moving around to avoid accidental extubation
d. Provide the patient with simple facts to assist with understanding of the situation

 

 

ANS:  D

The need for oxygen and survival predominates over all other human needs. According to Maslow’s hierarchy of human needs, lower-level, physiologic needs must be satisfied before an individual can move on to higher-level issues. Experiencing a significant physiologic stressor may completely consume all the patient’s available energy and thoughts, affecting his or her ability to interact, comprehend, and respond.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 65

OBJ:   Nursing Process Step: Implementation

TOP:   Patient and Family Education           MSC:  NCLEX: Safe and Effective Care Environment

 

  1. A lack of true understanding can often be misread by the nurse as noncompliance. Which of the following statements demonstrate effective questioning methods to assess a patient’s understanding?
a. “Do you take your heart medication every morning?”
b. “Can you tell me what you know about your different heart medications?”
c. “Do you take all of your medications?”
d. “Do you ever miss taking your medication?”

 

 

ANS:  B

Open-ended questions provide the nurse an opportunity to assess actual knowledge gaps rather than assume knowledge by obtaining a “yes” or “no” response. These types of questions also assist the patient and family to tell their story of the illness and communicate their perceptions of the experience. Questions that elicit only a “yes” or “no” response close off communication and do not provide for an interactive teaching–learning session.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 70

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Acute illness disrupts the patient’s and family’s normal routines and is extremely stressful. What coping mechanisms might the nurse expect the patient and/or family to display? (Select all that apply.)
a. Denial
b. Adaptation
c. Values
d. Anger
e. Disbelief

 

 

ANS:  A, D, E

Denial, disbelief, and anger are all examples of coping mechanisms that patients use to help in stressful situations. Adaptation is the ability to break down emotional barriers that affect willingness and readiness for learning. Values are considered sociocultural factors for coping with stress.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 60

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What are sources of physiologic stress in the acutely ill patient? (Select all that apply.)
a. Hypotension
b. Hypoxemia
c. Fever
d. Neurologic deficits
e. Eupnea

 

 

ANS:  A, B, C, D

Physiologic alterations in heart rate and blood pressure can be measured and taken into consideration during the teaching–learning encounter. Sources of physiologic stress in acutely ill patients include medications, pain, hypoxemia, decreased cerebral and peripheral perfusion, hypotension, fluid and electrolyte imbalances, infection, sensory alterations, fever, and neurologic deficits.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 61

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. According to Malcolm Knowles’ andragogy, what are characteristics of the adult learner? (Select all that apply.)
a. Autonomy
b. Experience
c. Instructor-driven assessments
d. Peer-directed motivation
e. Individualism

 

 

ANS:  A, B, E

Malcolm Knowles described these principles of adult learning in a model known as andragogy. Adult learning theory stresses concepts of individualism, self-assessment, self-direction, motivation, experience, and autonomy.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 60

OBJ:   Nursing Process Step: N/A              TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which questions can a nurse use to obtain assessment information to determine the immediate need for education? (Select all that apply.)
a. “How can we help you today?”
b. “Can you tell me why you take each medication?”
c. “Are you in pain?”
d. “Are these people your main support system?”
e. “How well do you understand the directions?”

 

 

ANS:  A, B, E

Generally, with practice and effort, it can be determined what educational information is needed in a brief period without much disruption in the routine care of the patient. Questions that elicit a “yes” or “no” response close off communication and do not provide an interactive teaching–learning session.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 60|Box 5-1

OBJ:   Nursing Process Step: Assessment   TOP:   Patient and Family Education

MSC:  NCLEX: Health Promotion and Maintenance

 

 

 

 

Chapter 23: Neurologic Disorders and Therapeutic Management

Urden: Critical Care Nursing, 8th Edition

 

MULTIPLE CHOICE

 

  1. What is one cause of metabolic coma?
a. Trauma
b. Ischemic stroke
c. Drug overdose
d. Intracerebral hemorrhage

 

 

ANS:  C

Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 589|Box 23-9

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents?
a. Epinephrine, hydrocortisone, and Benadryl
b. Dopamine, 10% dextrose in distilled water, and calcium chloride
c. Mannitol, dexamethasone, and sodium bicarbonate
d. Thiamine, glucose, and opioid antagonist

 

 

ANS:  D

The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 590

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which patient has the best prognosis based on the cause of coma?
a. A 36-year-old man with closed head injury
b. A 50-year-old woman with hepatic encephalopathy
c. A 46-year-old woman with subarachnoid hemorrhage
d. A 72-year-old man with hypertensive intracerebral hemorrhage

 

 

ANS:  A

Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 590

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival?
a. Decorticate posturing
b. Absent pupillary light reflexes
c. Decerebrate posturing
d. Central hyperventilation

 

 

ANS:  B

Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest. In a meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual cannot be predicted with 100% accuracy.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 590

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. How often should lubricating eye drops be administered to a patient in coma to prevent corneal epithelial breakdown?
a. 2 hours
b. 4 hours
c. 8 hours
d. 12 hours

 

 

ANS:  A

Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been effective in keeping the eyes moist.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 591

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study?
a. Magnetic resonance imaging
b. Noncontrast computed tomography
c. Contrast computed tomography
d. Lumbar puncture

 

 

ANS:  B

Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. In addition to excluding intracranial hemorrhage, CT can assist in identifying early neurologic complications and the cause of the insult. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 577

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms?
a. 1
b. 3
c. 6
d. 10

 

 

ANS:  B

National guidelines for the management of stroke are based on the results of the National Institute of Neurologic Disorders and Stroke rtPA Stroke Study. This study demonstrated that administration of recombinant tissue plasminogen activator within 3 hours of onset of the stroke was an effective and safe therapy for ischemic stroke. This time frame has now been expanded from 3 to 4.5 hours with additional excursion criteria.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 577

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke?
a. Hemorrhagic stroke
b. Intracerebral hemorrhages
c. Subarachnoid hemorrhages
d. Ischemic stroke

 

 

ANS:  D

Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 575

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs)?
a. Occurrence is greater in men than women younger than the age of 40 years old.
b. Occurrence is greater in men than women older than the age of 40 years old.
c. 90% of SAHs are caused by traumatic injury.
d. Patients with SAHs have a better survival rate than patients with arteriovenous malformations.

 

 

ANS:  A

Among people younger than 40 years, more men than women are likely to have subarachnoid hemorrhages (SAHs); among those older than 40 years, more women have SAHs. Hemorrhage from arteriovenous malformation rupture has a better chance of survival and is associated with an overall mortality rate of 10% to 15%. Ninety percent of aneurysms are congenital, the cause of which is unknown. The other 10% can be the result of traumatic injury (that stretches and tears the muscular middle layer of the arterial vessel) or infectious material.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   pp. 578-579

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. What is a pathologic consequence of an unruptured cerebral aneurysm?
a. It shunts blood away from the surrounding tissues.
b. It leaks blood into the subarachnoid space.
c. It causes damage the middle layer of the arterial wall.
d. It places pressure on the surrounding tissues.

 

 

ANS:  D

An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 579

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods?
a. First 24 hours
b. 4 to 12 days
c. 3 to 4 weeks
d. 3 to 6 months

 

 

ANS:  A

Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month. Mortality with aneurysmal rebleeding is approximately 70%.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 582

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Nursing management of a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention?
a. Administering osmotic diuretics and vasodilator agents
b. Providing the patient with a quiet environment
c. Maintaining the patient’s systolic blood pressure at 150 to 160 mm Hg
d. Keeping the patient’s central venous pressure at 5 to 8 mm Hg

 

 

ANS:  C

Hemodynamic augmentation therapy involves increasing the patient’s blood pressure and cardiac output with vasoactive medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the vasospastic area at higher pressures.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 583

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A ventriculoperitoneal shunt may be placed in a post-stroke patient to treat which complication?
a. Hyponatremia
b. Intracerebral hemorrhage
c. Spontaneous intracerebral hemorrhage
d. Hydrocephalus

 

 

ANS:  D

Treatment for hydrocephalus consists of placing a drain to remove cerebrospinal fluid. This can be accomplished temporarily by inserting a ventriculostomy or permanently by placing a ventriculoperitoneal shunt. Treatment for hyponatremia is sodium replenishment with isotonic fluids.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 584

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A male patient post right-sided stroke is experiencing hemiagnosia. This is evidenced by which finding?
a. The patient only reads the right side of the newspaper.
b. The patient refuses to acknowledge the left side of his body.
c. The patient is hyperresponsive when approached on the right side.
d. The patient attempts to comb his hair with a toothbrush.

 

 

ANS:  B

Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. This denial may range from inattention to refusing to acknowledge a paralysis by neglecting the involved side of the body or by denying ownership of the side, attributing the paralyzed arm or leg to someone else. The neglect also may extend to extrapersonal space. This defect most often results from right hemispheric brain damage that causes left hemiplegia.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   pp. 586-587

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. When an object is placed in the hand of a patient with neurologic impairment during assessment, the patient is unable to recognize the placement. What is this complication called?
a. Homonymous hemianopsia
b. Aphasia
c. Agnosia
d. Apraxia

 

 

ANS:  C

Agnosia is a disturbance in the perception of familiar sensory (eg, verbal, tactile, visual) information. Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body. Tactile agnosia is a perceptual disorder in which a patient is unable to recognize an object that has been placed in his or her hand by touch alone. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily. Optic radiations extend back to the occipital lobes. Visual defects restricted to a single field, right or left, are called homonymous hemianopsia. Aphasia is a loss of language abilities caused by brain injury, usually to the dominant hemisphere.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   pp. 586-587

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient has had an ischemic stroke and now having difficulty with speech. The nurse knows the patient is experiencing what problem?
a. Expressive aphasia
b. Global aphasia
c. Receptive aphasia
d. Apraxia

 

 

ANS:  A

Expressive aphasia, also known as motor, Broca, or nonfluent aphasia, is primarily a deficit in language output or speech production. Global aphasia results when a massive lesion affects the motor and sensory speech areas. The patient cannot transform sounds into words and cannot comprehend spoken words. Receptive aphasia, also referred to as sensory, Wernicke, or fluent aphasia, occurs when the connection between the primary auditory cortex in the temporal lobe and the angular gyrus in the parietal lobe is destroyed. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 587

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit?
a. The demyelination process of the peripheral nerves is irreversible.
b. The demyelination process is limited to the peripheral nervous system only.
c. The paralysis associated with the syndrome occurs in a descending pattern.
d. The most common cause of death is respiratory arrest.

 

 

ANS:  D

Most patients with Guillain-Barré syndrome (GBS) do not require admission to the critical care unit. However, the prototype of GBS, known as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), involves a rapidly progressive, ascending peripheral nerve dysfunction, which leads to paralysis that may produce respiratory failure. Because of the need for ventilatory support, AIDP is one of the few peripheral neurologic diseases that necessitates care in a critical care environment.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 591

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which nursing diagnosis has the highest priority in the nursing management plan for a patient with Guillain-Barré syndrome?
a. Imbalanced nutrition: less than body requirements related to lack of exogenous nutrients or increased metabolic demand
b. Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses
c. Risk for aspiration
d. Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment

 

 

ANS:  D

The most common cause of death of patients with Guillain-Barré syndrome (GBS) is respiratory arrest; thus, the highest nursing priority for a patient with GBS is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   pp. 591-592|Box 23-12

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) of the patient’s head reveals a large left parietal area bleed. Patient assessment includes temperature (T), 98.7° F; pulse (P), 98 beats/min and thready; respirations (R), 8 breaths/min; and blood pressure (BP), 168/100 mm Hg. Initial management of the patient includes which intervention?
a. Placing the patient in the Trendelenburg position
b. Administering an antihypertensive agent
c. Initiating induced hypertensive therapy
d. Intubating and ventilating the patient

 

 

ANS:  D

Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 585

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient’s head reveals a large left parietal area bleed. Based on the type of stroke, which signs and symptoms might the patient exhibit?
a. Right-sided hemiplegia and receptive aphasia
b. Left-sided hemiplegia and tactile agnosia
c. Decorticate posturing and unequal pupils
d. Unilateral neglect and dressing apraxia

 

 

ANS:  A

Damage to the dominant hemisphere produces problems with speech and language and abstract and analytic skills.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   pp. 585-586

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A female right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient’s head reveals a large left parietal area bleed. While assisting with personal care, the nurse notes that the patient is unable to comb her hair with her left hand. The nurse suspects the patient may be experiencing which complication?
a. Agnosia
b. Apraxia
c. Broca aphasia
d. Wernicke aphasia

 

 

ANS:  B

Lesions in the parietal lobe, as well as in other cortical structures, can result in apraxia, an inability to perform a learned movement voluntarily.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 587

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient has been experiencing drowsiness, confusion, and slight focal deficits for several days. The initial noncontract computed tomography (CT) findings are negative. The patient is being prepared for a lumbar puncture. What appearance does the nurse anticipate that the cerebrospinal fluid (CSF) would look?
a. Cloudy
b. Bloody
c. Xanthochromic
d. Clear

 

 

ANS:  B

If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis. CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 581|Box 23-7

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Downward displacement of the hemispheres, basal ganglia, and diencephalon through the tentorial notch is indicative of what type of herniation?
a. Central
b. Uncal
c. Cingulate
d. Infratentorial

 

 

ANS:  A

These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri. The two infratentorial herniation syndromes are upward transtentorial herniation and downward cerebellar herniation.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 603

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which intervention should be considered LAST in treating uncontrolled intracranial hypertension?
a. Sedatives
b. Analgesics
c. Barbiturates
d. Hyperventilation

 

 

ANS:  C

Barbiturate therapy is a treatment protocol developed for the management of uncontrolled intracranial hypertension that has not responded to the conventional treatments previously described. The two most commonly used drugs in high-dose barbiturate therapy are pentobarbital and thiopental. The goal with either of these drugs is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 602

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which medication is a fast-acting, short-duration agent used for breakthrough seizures?
a. Lorazepam
b. Phenytoin
c. Phenobarbital
d. Midazolam

 

 

ANS:  A

Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached. Phenytoin is the recommended medication for seizure prophylaxis. Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 601

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which patient position is optimal to prevent elevated intracranial (ICP) pressures?
a. The head of the bed elevated 30 to 40 degrees
b. Supine with the patient’s neck in a neutral alignment
c. Individualized head position to minimize ICP measurements
d. The head of the bed elevated with flexion of the hips

 

 

ANS:  C

The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 596|Box 23-20

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. What is the target range for PaCO2 in the patient with intracranial hypertension?
a. 25 to 30 mm Hg
b. 25 to 35 mm Hg
c. 35 to 40 mm Hg
d. 33 to 37 mm Hg

 

 

ANS:  D

The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 599

OBJ:   Nursing Process Step: Evaluation     TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. After neurosurgery, the patient is at risk of developing what problem?
a. Aspiration
b. Diabetes mellitus
c. Seizures
d. Corneal abrasions

 

 

ANS:  C

After neurosurgery, the patient is at risk for infection, corneal abrasions, and injury from falls or seizures. After neurosurgery, patients are at risk for a variety of infections, including meningitis, cerebral abscesses, bone flap infections, and subdural empyema.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 597

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which nursing intervention will help prevent spikes in intracranial pressure in the post-neurosurgical patient?
a. Keep the head of the bed elevated 45 to 90 degrees.
b. Administer an antiemetic to prevent vomiting.
c. Provide fluid restriction.
d. Help with turn, cough, and deep breathe exercises.

 

 

ANS:  B

Postoperative vomiting must be avoided to prevent sharp spikes in intracranial pressure (ICP) in the postoperative neurosurgical patient. Antiemetics are administered as soon as nausea is apparent. Fluid restriction may be ordered as a routine measure to lessen the severity of cerebral edema or as treatment for the fluid and electrolyte imbalances associated with the syndrome of inappropriate antidiuretic hormone secretion. Most craniotomy patients can be turned from side to side within these restrictions, using pillows for support, except in some cases of extensive tumor removal, cranioplasty, and when the bone flap is not replaced. Routine pulmonary care is used to maintain airway clearance and prevent pulmonary complications. To prevent dangerous elevations in ICP, this care measure must be performed using proper technique and at time intervals that are adequately spaced from other patient care activities.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 597

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. The nurse is caring for a patient who is had trans-sphenoidal surgery for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The provider requests the drainage be tested for the presence of glucose. Why did the physician order this test?
a. To assess for an infection
b. To check for a shift in osmolality
c. To check for occult blood
d. To assess for a cerebrospinal fluid leak

 

 

ANS:  D

To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A CSF leak is confirmed by glucose values of 30 mg/dL or greater.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 596

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. What is one of the earliest signs of increased intracranial pressure (ICP)?
a. Cushing triad
b. Decerebrate posturing (abnormal extension)
c. Change in level of consciousness
d. Increase in pupillary size

 

 

ANS:  C

One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 577

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which independent nursing measures can assist in reducing increased intracranial pressure (ICP)?
a. Decreasing the ventilator rate
b. Decreasing noxious stimuli
c. Frequent orientation checks
d. Administration of loop diuretics

 

 

ANS:  B

A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increasing intracranial pressure.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 602

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)?
a. Mannitol
b. Furosemide
c. Urea
d. Glycerol

 

 

ANS:  A

The most widely used diuretic is mannitol, a large-molecule agent that is retained almost entirely in the extracellular compartment and has little of the rebound effect observed with other osmotic diuretics. Administration of mannitol increases cerebral blood flow and thus induces cerebral vasoconstriction as part of the brain’s autoregulatory response to keep blood flow constant.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 602

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. What are the most common medications used in high-dose barbiturate therapy?
a. Phenytoin and fosphenytoin
b. Mannitol and nimodipine
c. Lidocaine and phenobarbital
d. Pentobarbital and thiopental

 

 

ANS:  D

The goal with either drug is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained. Phenytoin and fosphenytoin are anticonvulsants. Mannitol is an osmotic diuretic, lidocaine is a local anesthetic, and nimodipine is a calcium channel blocker.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   pp. 602-603|Table 23-5

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. Which medication is prescribed to decrease cerebral vasospasm?
a. Phenytoin
b. Phenobarbital
c. Nimodipine
d. Vecuronium

 

 

ANS:  C

Nimodipine is used to decrease cerebral vasospasm.

 

PTS:   1                    DIF:    Cognitive Level: Remembering        REF:   p. 604|Box 23-5

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient is admitted with an acute head injury after a motor vehicle accident. The patient is intubated and ventilated, and a ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the ventriculostomy?
a. Instillation of mannitol
b. Drainage of subdural hematoma
c. Brain tissue sampling
d. Cerebrospinal fluid drainage

 

 

ANS:  D

Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 596

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. The extrusion of cerebral tissue through the cranium is what type of herniation?
a. Transcalvarial
b. Uncal
c. Cingulate
d. Transtentorial

 

 

ANS:  A

Transcalvarial herniation is the extrusion of cerebral tissue through the cranium. In the presence of severe cerebral edema, transcalvarial herniation occurs through an opening from a skull fracture or craniotomy site. These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 603

OBJ:   Nursing Process Step: Assessment   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient becomes flaccid with fixed and dilated pupils. The patient’s intracranial pressure (ICP) falls from 65 to 12 mm Hg. What should the nurse suspect is happening?
a. The patient is having a seizure.
b. The patient’s brain has herniated.
c. The patient’s cerebral edema is resolving.
d. The patient is excessively dehydrated from the mannitol.

 

 

ANS:  B

Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations. Signs and symptoms of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 602

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient’s ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Given that the practitioner has left appropriate orders, which action should the nurse take next?
a. No action is required.
b. Administer mannitol 1 to 2 g/kg IV.
c. Place the patient supine and flat in bed.
d. Suction the patient.

 

 

ANS:  B

Mannitol is an osmotic diuretic and will pull swelling out of edematous brain tissue, thereby decreasing intracranial pressure (ICP). Having the patient lie flat in bed will impair venous drainage from the head and worsen ICP. Suctioning will cause increased intrathoracic pressure, which will also worsen the already elevated ICP.

 

PTS:   1                    DIF:    Cognitive Level: Applying               REF:   p. 602|p. 604|Table 23-5

OBJ:   Nursing Process Step: Intervention   TOP:   Trauma

MSC:  NCLEX: Physiologic Integrity

 

  1. The patient has uncontrolled intracranial pressure and now is receiving high-dose barbiturate therapy. The nursing management plan for this patient should include monitoring the patient for what complication?
a. Hypothermia
b. Hypotension
c. Myocardial depression
d. Dehydration

 

 

ANS:  B

Hypotension, the most common complication in barbiturate therapy, results from peripheral vasodilation and can be compounded in an already dehydrated patient who has received large doses of an osmotic diuretic in an attempt to control intracranial pressure. Myocardial depression results from cardiac muscle suppression and can be avoided by frequent monitoring of fluid status, cardiac output, and serum drug levels.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 602

OBJ:   Nursing Process Step: Diagnosis      TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient has been admitted post craniotomy for a brain tumor. The nursing management plan should include monitoring the patient for what complication?
a. Diabetes mellitus
b. Fluid retention
c. Intracranial hypotension
d. Surgical hemorrhage

 

 

ANS:  D

Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal fluid leak, and deep venous thrombosis.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 595

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient has been told he has a nonencapsulated tumor that has infiltrated the brain tissue. Why type of tumor does the nurse suspect the patient has?
a. Angioma
b. Pituitary adenoma
c. Meningioma
d. Glioma

 

 

ANS:  D

Gliomas are nonencapsulated; tend to infiltrate brain tissue; arise in any part of brain connective tissue; infiltrate primarily cerebral hemisphere tissue; are not well outlined, so they are difficult to excise completely; and grow rapidly. Angiomas arise from vascular structures and are usually difficult to resect. Pituitary adenomas arise from various tissues. Meningiomas arise from meningeal coverings of brain and are usually encapsulated.

 

PTS:   1                    DIF:    Cognitive Level: Understanding       REF:   p. 594|Table 23-3

OBJ:   Nursing Process Step: Intervention   TOP:   Neurologic

MSC:  NCLEX: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. The patient has sustained an ischemic stroke involving the left cerebral hemisphere. Which of the following neurologic abnormalities would you expect to see? (Select all that apply.)
a. Aphasia
b. Left visual field defect
c. Difficulty balancing his checkbook
d. Ataxic gait
e. Somnolence

 

 

ANS:  A, C

With strokes in the left (dominant) hemisphere, patients may have aphasia; right hemiparesis; right-sided sensory loss; right visual field defect; poor right conjugate gaze; dysarthria; and difficulty in reading, writing, or calculating. With strokes in the right (nondominant) hemisphere, patients may have neglect of the left visual space, left visual field defect, left hemiparesis, left-sided sensory loss, poor left conjugate gaze, extinction of left-sided stimuli, dysarthria, and spatial disorientation. With strokes in the brainstem, cerebellum, and posterior hemisphere, patients may have motor or sensory loss in all four limbs, crossed signs, limb or gait ataxia, dysarthria, disconjugate gaze, nystagmus, amnesia, and bilateral visual field defects.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing             REF:   p. 577|Box 23-1

OBJ:   Nursing Process Step: Assessment

TOP:   Neurologic Disorders and Therapeutic Management

MSC:  NCLEX: Physiologic Integrity

 

  1. A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse checks the medication administration record to make sure the patient does not have which medications for the next 24 hours? (Select all that apply.)
a. Aspirin
b. Sodium nitroprusside
c. Warfarin
d. Labetalol
e. Any antiplatelet drugs

 

 

ANS:  A, C, E

The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other antithrombotic or antiplatelet drugs for at least 24 hours after treatment. Sodium nitroprusside and labetalol are used to manage blood pressure after a stroke.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing             REF:   p. 577

OBJ:   Nursing Process Step: Assessment

TOP:   Neurologic Disorders and Therapeutic Management

MSC:  NCLEX: Physiologic Integrity

 

 

 

 

Chapter 31: Endocrine Clinical Assessment and Diagnostic Procedures

Urden: Critical Care Nursing, 8th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes. Which laboratory results would the nurse note confirming this diagnosis?
a. Hemoglobin A1C of 3%
b. Absence of ketones in the urine
c. Presence of ketones in the blood
d. Fasting glucose of 105 mg/dL

 

 

ANS:   C

Ketone bodies are a byproduct of rapid fat breakdown. Ketone blood levels rise in acute illness, fasting, and with sustained elevation of blood glucose in type 1 diabetes in the absence of insulin. The patient would also have ketones in the urine, a hemoglobin A1C greater than 6%, and a fasting glucose greater than 125 mg/dL.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 718

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes. The nurse notes that the patient is extremely dehydrated. To make this assessment, what did the nurse evaluate?
a. Skin turgor
b. Nail bed color
c. Capillary refill
d. Skin temperature

 

 

ANS:   A

A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is resilient and returns to its original position in less than 3 seconds after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 718

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with diabetic ketoacidosis. The nurse requests the practitioner order a glycosylated hemoglobin (HbA1C). What information does this test provide to the health care team?
a. It is an indicator of the patient’s average blood glucose level over the previous 3 to 4 months.
b. It compares blood glucose levels with serum hemoglobin over the previous 3 to 4 weeks.
c. It is an indicator of the patient’s highest blood ketone level over the past month.
d. It associates the serum and urine glucose levels and is an indicator of kidney involvement.

 

 

ANS:   A

The glycated hemoglobin test (also known as the glycosylated hemoglobin, or HbA1C or A1C) provides information about the average amount of glucose that has been present in the patient’s bloodstream over the previous 3 to 4 months. During the 120-day life span of red blood cells (erythrocytes), the hemoglobin within each cell binds to the available blood glucose through a process known as glycosylation.

 

PTS:    1                      DIF:    Cognitive Level: Understanding       REF:    p. 717

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. The nurse is caring for a patient with a traumatic brain injury. The nurse suspects the patient is developing diabetes insipidus. Which test or procedure would confirm this diagnosis?
a. Skull radiographs
b. Serum glucose level
c. Water deprivation test
d. Antidiuretic hormone (ADH) stimulation test

 

 

ANS:   D

Serum antidiuretic hormone (ADH) levels are compared with the blood and urine osmolality to differentiate syndrome of inappropriate antidiuretic hormone (SIADH) from central diabetes insipidus (DI). Increased ADH levels in the bloodstream compared with a low serum osmolality and elevated urine osmolality confirms the diagnosis of SIADH. Reduced levels of serum ADH in a patient with high serum osmolality, hypernatremia, and reduced urine concentration signal central DI.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 719

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient has been admitted who is suspected of having thyrotoxicosis. Which symptom would support this diagnosis?
a. Lethargy despite adequate sleep
b. Bradycardia not related to medications
c. Constipation despite laxatives
d. Weight loss despite increased appetite

 

 

ANS:   D

Signs and symptoms of thyrotoxicosis include tremors, insomnia, increased appetite, diarrhea, muscle weakness or wasting, and a change in menstruation.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 720|Box 31-2

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient has been admitted who is suspected of having thyrotoxicosis. Which laboratory findings would confirm this diagnosis?
a. Very low thyroid-stimulating hormone (TSH)
b. Decreased T3 uptake ratio
c. Increased serum osmolality
d. Decreased urine osmolality

 

 

ANS:   A

Hyperthyroidism (thyrotoxicosis) is indicated by very low thyroid-stimulating hormone level, high serum T4, and an increased T3:T4 ratio.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 731

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with severe hyperglycemia due to new-onset type 1 diabetes mellitus. Which signs and symptoms obtained as part of the patient’s history might indicate the presence of hyperglycemia?
a. Recent episodes of tachycardia and missed heart beats
b. Decreased urine output accompanied by peripheral edema
c. Periods of hyperactivity with weight gain
d. Increased thirst and increased urinary output

 

 

ANS:   D

The patient or family member may relay information about recent, unexplained changes in weight, thirst, hunger, and urination patterns.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 717

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with severe hyperglycemia due to new-onset type 1 diabetes mellitus. The nurse notes a sweet-smelling odor on the patient’s exhaled breath. What causes this phenomenon?
a. Metabolic alkalosis
b. Ketoacidosis
c. Glycosylation
d. Dehydration

 

 

ANS:   B

Ketoacidosis results in the patient’s breathing becoming deep and rapid (Kussmaul respirations) and the patient’s breath having a fruity odor. Metabolic alkalosis and dehydration do not cause this phenomenon. Glycosylation is when the hemoglobin within each cell binds to the available blood glucose.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 716

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is reporting a headache, fatigue, abdominal pain, and blurred vision. The nurse knows that these signs may indicate the patient has what problem?
a. Hypothyroidism
b. Pituitary tumor
c. Cushing syndrome
d. Hyperglycemia

 

 

ANS:   D

Because severe hyperglycemia affects a variety of body systems, all systems are assessed. The patient may complain of blurred vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, and abdominal pain.

 

PTS:    1                      DIF:    Cognitive Level: Understanding       REF:    p. 716|Box 31-1

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient has been admitted with abdominal pain. The nurse notes that the patient’s fasting blood glucose is 120 mg/dL. Which statement regarding this finding is accurate?
a. This is a normal finding in critically ill patients.
b. This finding is indicative of prediabetes, but another test should be done to confirm.
c. This finding is lower than what the nurse would expect in a patient receiving intravenous fluids.
d. This finding is indicative of diabetic ketoacidosis.

 

 

ANS:   B

A normal fasting plasma glucose (FPG) level is between 70 and 110 mg/dL. An FPG level between 110 and 126 mg/dL identifies a person who is prediabetic. An FPG level of greater than 126 mg/dL (7 mmol/L) is diagnostic of diabetes. In nonurgent settings, the test is repeated on another day to make sure the result is accurate.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 717|Table 31-1

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A nurse is teaching a patient with diabetes mellitus. The patient asks the nurse what is an acceptable HbA1c level for him. What should the nurse tell the patient?
a. An acceptable level is less than 5.4%.
b. An acceptable level is less than 6.5%.
c. An acceptable level is determined by your practitioner.
d. It is dependent on your age.

 

 

ANS:   A

A normal HbA1C value is less than 5.4%, with an acceptable target level for patients with diabetes below 6.5%.

 

PTS:    1                      DIF:    Cognitive Level: Remembering         REF:    p. 717

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. The nurse is caring for a patient with a traumatic brain injury. Yesterday the patient weighed 62 kg and today the patient weighs 60 kg. How much fluid loss does this change in weight reflect?
a. 1 L
b. 2 L
c. 4 L
d. 10 L

 

 

ANS:   B

Daily weight changes coincide with fluid retention and fluid loss. 1 L of fluid lost or retained is equal to approximately 2.2 lb, or 1 kg, of weight gained or lost. This patient lost 2 kg of weight, which is equivalent to 2 L of fluid.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 718

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with hyponatremia. The practitioner suspects the patient may have syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and orders a serum ADH level for the next morning. Which medications must be stopped or withheld at least 8 hours prior to the test?
a. Insulin and furosemide
b. Morphine and carbamazepine
c. Digoxin and potassium
d. Heparin and lopressor

 

 

ANS:   B

To prepare the patient for the test, all drugs that may alter the release of antidiuretic hormone (ADH) are withheld for a minimum of 8 hours. Common medications that affect ADH levels include morphine sulfate, lithium carbonate, chlorothiazide, carbamazepine, oxytocin, nicotine, alcohol, and selective serotonin reuptake inhibitors.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 718

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with hypernatremia secondary to neurogenic diabetes insipidus. The nurse notes that the patient’s serum osmolality is 350 mOsm/kg. What does this finding indicate?
a. The patient is overhydrated.
b. The patient’s serum osmolality is normal.
c. The patient is dehydrated.
d. The patient is hypothyroid.

 

 

ANS:   C

Values for serum osmolality in the bloodstream range from 275 to 295 mOsm/kg H2O. Increased serum osmolality stimulates the release of antidiuretic hormone, which in turn reduces the amount of water lost through the kidney.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 719

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with hypernatremia secondary to diabetes insipidus (DI). Which test would help the practitioner differentiate between central and nephrogenic DI?
a. Water deprivation test
b. Serum osmolality
c. Serum antidiuretic hormone level
d. Antidiuretic hormone (ADH) test

 

 

ANS:   D

The antidiuretic hormone test is used to differentiate between neurogenic diabetes insipidus (DI) (central) and nephrogenic (kidney) DI. In severe central DI, in which the pituitary is affected, the urine osmolality shows a significant increase (becomes more concentrated), which indicates that the cell receptor sites on the kidney tubules are responsive to vasopressin. Test results in which urine osmolality remains unchanged indicate nephrogenic DI, suggesting kidney dysfunction because the kidneys are no longer responsive to antidiuretic hormone.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 719

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with hypernatremia secondary to diabetes insipidus (DI). The practitioner suspects the patient has neurogenic DI. Which finding would confirm that diagnosis?
a. A slight increase in urine osmolality
b. A decrease in urine output
c. A decrease in serum osmolality
d. No change in urine osmolality

 

 

ANS:   D

In cases of severe central diabetes insipidus (DI)d the urine osmolality shows a significant increase (becomes more concentrated). Test results in which urine osmolality remains unchanged indicate nephrogenic DI.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 719

OBJ:    Nursing Process Step: Evaluation      TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient has been admitted with a brain mass. The practitioner suspects it might be a pituitary tumor and orders a computed tomography (CT) scan. What area of brain should be scanned to confirm this diagnosis?
a. Frontal lobe
b. Base of the skull
c. Temporal lobe
d. Anterior fossa

 

 

ANS:   B

Computed tomography (CT) of the base of the skull identifies pituitary tumors, blood clots, cysts, nodules, or other soft tissue masses.

 

PTS:    1                      DIF:    Cognitive Level: Understanding       REF:    p. 719

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient reports losing weight even though she eats “everything in sight.” She also reports tremors and diarrhea. The nurse suspects the patient may have what problem?
a. Hypothyroidism
b. Diabetes mellitus
c. Hyperthyroidism
d. Pituitary tumor

 

 

ANS:   C

Weight loss, increased appetite, tremors, insomnia, and diarrhea are symptoms of hyperthyroidism.

 

PTS:    1                      DIF:    Cognitive Level: Understanding       REF:    p. 720|Box 31-2

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient has been admitted with uncontrolled atrial fibrillation and muscle wasting. The practitioner suspects the patient may have a thyroid disorder. The nurse auscultates a bruit over the thyroid. What does this finding indicate?
a. Normal function
b. Enlargement of the thyroid
c. Hypoplasia of the thyroid
d. Tumor of the thyroid

 

 

ANS:   B

Auscultation of the thyroid is accomplished by use of the bell portion of the stethoscope to identify a bruit or blowing noise from the circulation through the thyroid gland. The presence of a bruit indicates enlargement of the thyroid as evidenced by increased blood flow through the glandular tissue.

 

PTS:    1                      DIF:    Cognitive Level: Remembering         REF:    p. 720

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is being evaluated for thyroid dysfunction. The patient’s medications include aspirin, digoxin, chlorothiazide, and insulin. The nurse knows that the laboratory work may be affected by which of these medications?
a. Aspirin
b. Digoxin
c. Insulin
d. Chlorothiazide

 

 

ANS:   A

Several drugs increase the serum level of T4 by displacing protein-bound T4. Drugs that displace T4, including heparin (both unfractionated and low-molecular-weight heparins), cause an increase in serum T4 levels. Salicylates (aspirin) and furosemide (Lasix) also raise T4 serum levels by the same mechanism.

 

PTS:    1                      DIF:    Cognitive Level: Understanding       REF:    p. 721|Table 31-5

OBJ:    Nursing Process Step: Assessment    TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient has been admitted with uncontrolled atrial fibrillation and muscle wasting. The practitioner suspects the patient may have a thyroid disorder. The nurse anticipates the practitioner will initially order which diagnostic procedure to visualize the thyroid?
a. Magnetic resonance imaging (MRI)
b. Ultrasound
c. Biopsy
d. Computed tomography (CT)

 

 

ANS:   B

Diagnostic tests often begin with ultrasonography to visualize a thyroid nodule or tumor.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 721

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is being evaluated for thyroid dysfunction. The laboratory findings include a decreased serum free thyroxine (T4) level and an elevated thyroid-stimulating hormone (TSH) level. These findings confirm which diagnosis?
a. Cushing syndrome
b. Addison disease
c. Thyrotoxicosis
d. Hypothyroidism

 

 

ANS:   D

Hypothyroidism is indicated by a high thyroid-stimulating hormone (TSH) and low serum T4 levels. Thyrotoxicosis is hyperthyroidism and is indicated by very low TSH, high serum T4, and increased T3:T4 ratio. Addison disease is a rare disorder of the adrenal cortex that involves hyposecretion of glucocorticoids (cortisol), sometimes occurring with hyposecretion of mineralocorticoids (aldosterone). Cushing syndrome is caused by the excess release of the glucocorticoid hormone cortisol.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing               REF:    pp. 720-721

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient has been admitted with multiple trauma due to a motor vehicle accident several weeks ago. Given the prolonged critical illness, the nurse knows the patient may no longer secrete adequate amounts of what hormone?
a. Aldosterone
b. Adrenocorticotropic hormone (ACTH)
c. Cortisol
d. Antidiuretic hormone (ADH)

 

 

ANS:   C

Cortisol is secreted in response to physiologic stress as a result of infection, trauma, and hypoglycemia. Early in critical illness, a rise in cortisol levels can be documented. However, over time the adrenal gland may not be able to secrete adequate amounts of stress hormones, especially when critical illness is prolonged. Aldosterone is secreted in response to intravascular hypovolemia.

 

PTS:    1                      DIF:    Cognitive Level: Understanding       REF:    p. 721

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A nurse is initiating a patient teaching plan for a patient with hypothyroidism. The patient is currently taking salicylates, lithium, and sulfonamides. It is important that the nurse tell the patient that these medications influence thyroid levels. How are thyroid levels affected by these medications?
a. They increase T3
b. They increasing T4
c. They decrease T3
d. They decrease T4

 

 

ANS:   C

Salicylates, lithium, and sulfonamides can cause a decrease in T3 levels.

 

PTS:    1                      DIF:    Cognitive Level: Understanding       REF:    p. 720|Table 31-4

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is diagnosed with a pheochromocytoma. What signs or symptoms might the nurse expect to see in this patient?
a. Hypertension and tachycardia
b. Weight gain and acne
c. Diarrhea and facial swelling
d. Blurred vision and poor skin turgor

 

 

ANS:   A

Signs and symptoms of pheochromocytoma include hypertension and tachycardia. Weight gain and acne are signs of Cushing syndrome. Diarrhea and facial swelling are signs of hyperthyroidism. Blurred vision and poor skin turgor are signs of hyperglycemia.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 723

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient is admitted with critical hypotension, hyperkalemia, hyponatremia, and hypoglycemia. The nurse knows that these symptoms are highly suggestive of which disorder?
a. Myxedema
b. Diabetes insipidus
c. Addisonian crisis
d. Cushing syndrome

 

 

ANS:   C

An Addisonian crisis is a life-threatening condition in which the adrenal gland is almost nonfunctional, usually because of destruction of adrenal tissue. The patient presents acutely with critical hypotension, an elevated serum potassium level (hyperkalemia), a low serum sodium level (hyponatremia), and hypoglycemia.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 723

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient was admitted with asthma who has been on steroids for a long time. The nurse knows that this patient is at risk of developing secondary Cushing syndrome. What would be the cause of this condition?
a. Pharmacologic glucocorticoids
b. Pharmacologic mineralocorticoids
c. Cortisol
d. Aldosterone

 

 

ANS:   A

Symptoms identical to those of primary Cushing syndrome occur in patients with the secondary form who chronically take pharmacologic doses of glucocorticoids, for example, transplant recipients who take steroids to prevent solid organ rejection, patients with chronic obstructive pulmonary disease, or those with chronic inflammatory conditions. Cortisol and aldosterone are hormones released by the adrenal gland.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 722

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. A patient is admitted with Cushing syndrome. Which findings would the nurse expect to note as confirming this diagnosis? (Select all that apply.)
a. Hirsutism
b. Rounded face
c. Hypotension
d. Decreased libido
e. Scleroderma
f. Fatigue and weakness

 

 

ANS:   A, B, D, F

Signs and symptoms of Cushing syndrome include hypertension, thin skin that bruises easily, and poor wound healing.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 722|Box 31-3

OBJ:    Nursing Process Step: Diagnosis       TOP:    Endocrine

MSC:   NCLEX: Physiologic Integrity

 

  1. The nurse is managing a patient with hyperglycemia. Which findings would the nurse expect to note to support this diagnosis? (Select all that apply.)
a. Anorexia
b. Abdominal pain
c. Bradycardia
d. Fluid overload
e. Change in level of consciousness
f. Kussmaul respirations

 

 

ANS:   A, B, E, F

More than likely the patient with hyperglycemia will be fluid volume depleted and tachycardic.

 

PTS:    1                      DIF:    Cognitive Level: Applying

REF:    pp. 716-717|Box 31-1                        OBJ:    Nursing Process Step: Assessment

TOP:    Endocrine Clinical Assessment and Diagnostic Procedures

MSC:   NCLEX: Physiologic Integrity

 

  1. A patient with thyrotoxicosis is admitted. Which laboratory tests would the nurse expect to be ordered for this patient? (Select all that apply.)
a. Total serum triiodothyronine (TT3)
b. Total serum thyroxine (TT4)
c. Free urine thyroid stimulating hormone
d. Total urine thyroxine
e. Thyroglobulin (Tg)
f. Free thyroxine (T4)

 

 

ANS:   A, B, E, F

Thyroid tests include total serum thyroxine, free thyroxine, total serum triiodothyronine, free triiodothyronine, thyroid-stimulating hormone (thyrotropin), and thyroglobulin.

 

PTS:    1                      DIF:    Cognitive Level: Applying                REF:    p. 720|Table 31-2

OBJ:    Nursing Process Step: Assessment

TOP:    Endocrine Clinical Assessment and Diagnostic Procedures

MSC:   NCLEX: Physiologic Integrity

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