Physiological Adaptation

The nurse notes the patient in Sierra Leone has anemia on peripheral blood smear. The patient reports pins and needles in both feet and mouth soreness. Which condition explains the patient's symptoms?

The patient is admitted due to concern for a cerebrovascular accident in the brainstem. Which reflexes does the nurse use to assess the integrity of the brainstem? Select all that apply.

Following a motor vehicle accident, the patient is brought to the emergency department with concern for a brainstem injury. Which tests are performed to assess the integrity of this patient’s brainstem? Select all that apply.

The nurse uses the caloric and doll’s eyes reflex tests to assess the functions of which cranial nerves in the comatose patient? Select all that apply.

The patient has signs of dangerously increased intracranial pressure following a traumatic brain injury. The nurse prepares the patient for the insertion of which intracranial pressure monitoring device considered to be the gold standard?

The 38-year-old patient has increased intracranial pressure following a massive stroke. Select the vital signs that together indicate the patient is at an immediate risk for brainstem herniation.

The unconscious patient with elevated intracranial pressure secondary to an ischemic stroke has a jugular bulb catheter in place to monitor cerebral oxygenation (SJO₂). The patient’s oxygen saturation (read by peripheral pulse oximetry probe) is 98% on 30% FiO₂ administered via endotracheal tube. The SJO₂ is 85%. How does the nurse interpret these results?

The patient in the intensive care unit is intubated, sedated, and chemically paralyzed following decompensation due to necrotizing pneumonia. During the routine neurological check, the nurse notes these pupils: How does the nurse interpret this assessment?

The unconscious patient presents with the following respiratory pattern: The nurse anticipates further testing will reveal which condition?

The patient with severely elevated intracranial pressure that has been well-controlled with medication and CSF drainage is intubated and sedated; the most recent arterial blood results are as follows: pH = 7.32, pCO2 = 35 mm Hg, PaO2 = 58, HCO3- = 16, Base excess = -7. The nurse advocates for which order to change ventilatory support?

The patient who has severely elevated intracranial pressure following a traumatic brain injury is intubated, sedated, and chemically paralyzed. Which intervention does the nurse include in the plan of care?

What is the rationale for using hyperventilation as management for acute elevated intracranial pressure?

The patient presents to the emergency department (ED) with significant respiratory distress. Decreases in which patient characteristics support a diagnosis of restrictive pulmonary disease? Select all that apply.

The patient is hospitalized with severe asthma. Which assessment prompts the nurse to call the rapid response team?

Which vital sign is most indicative of severe air trapping?

The patient with severe asthma is found to be pale, diaphoretic, and agitated. Which assessment is most concerning?

The patient receiving inhaled nitric oxide (iNO) for severe pulmonary hypertension experiences an abrupt decrease in oxygen saturation. Which action does the nurse take first?

The 66-year-old patient with congestive heart failure is brought to the emergency department (ED) via ambulance with complaints of respiratory distress and increasing oxygen requirement. Which assessment indicates the patient is experiencing acute respiratory distress syndrome (ARDS) rather than a congestive heart failure (CHF) exacerbation?

Which are indirect causes of acute respiratory distress syndrome (ARDS)? Select all that apply.

The patient with acute respiratory distress syndrome (ARDS) experiences destruction of type II pneumocytes. This damage first results in which pathophysiological event?

The destruction of type I pneumocytes caused by acute respiratory distress syndrome (ARDS) is associated with which assessment characteristic?

Upon auscultation of the anterior chest wall, the nurse notes a rubbing sound. Which action does the nurse take next?

The patient presents with a blood pressure of 135/95 mm Hg and appears jaundiced. She has a history of alcoholism, cirrhosis, and untreated hepatitis C. While the oncoming nurse is receiving report, the patient begins vomiting a large amount of blood. The nurse knows which to be the most likely cause of the patient’s hematemesis?

A man is admitted to the hospital for treatment of burns caused by a brush fire. He was attempting to control the flames and his clothes caught fire. He has burns of various depths on the front and back of both arms, his back, and the back of his head. What is the estimated total body surface area burned?

The patient has returned from abdominal surgery with a gauze dressing. The nurse notes a moderate amount of sanguineous drainage on the dressing. Which action does the nurse take?

In the post-anesthesia care unit (PACU) 30 minutes after surgery, the patient is noted to have a blue tinge around the lips. Which action does the nurse take first?

The nurse is assessing the patient 4 hours after a cholecystectomy and notes the skin around the umbilicus to be blue. The nurse contacts the provider to report which positive sign?

The patient underwent colon resection one day ago. The nurse is performing a shift assessment and notes absent bowel sounds after listening for 5 minutes. Which action by the nurse is most appropriate?

The patient has not yet voided in the 3 hours following a total knee replacement surgery. Which action by the nurse is appropriate?

The nurse is checking on the patient who underwent cardiac catheterization via the femoral artery 2 hours after the procedure. The patient appears to be sleeping and the nurse notes that the bruise at the insertion site has increased in size since the last assessment. Which action does the nurse take first?

The patient is 24-hours-postop from a pelvic reconstruction surgery after fracturing the pelvis in a fall. The patient reports severe abdominal pain and nausea. Upon assessment, the patient’s abdomen is grossly distended and firm. The patient’s skin is diaphoretic and the patient is tachypneic and tachycardic. Pulses and capillary refill time are adequate. During the assessment, the patient vomits a moderate amount of light green liquid. The nurse contacts the provider to report suspicion of which postoperative complication?

The patient has not defecated for 24 hours after an appendectomy. The patient’s abdomen is distended and the patient reports nausea. Upon auscultation, the nurse notes absent bowel sounds after 5 minutes of auscultation. Which action does the nurse take first?

The nurse is called to the intubated patient’s room by the patient's child who reports a large gush of red-tinged fluid from a transverse abdominal wound after the patient coughed. While calling for help, the nurse ensures the patients bed is set to which degree angle?

On day four postop following an open abdominal surgery, the patient develops a cough. During an assessment, the patient coughs, and the wound dehisces. The nurse notes intestinal loops are visible outside of the wound. Which initial intervention by the nurse is appropriate?

The patient has been taking oral oxycodone for 5 months and has experienced relief of pain caused by a bulging disc in the lower back. The patient presents to the clinic to report breakthrough pain that is more severe than before treatment. Which action by the nurse is most appropriate?

The patient with damage to the anterior horn of the spinal cord will have which deficiency?

The patient is brought to the emergency department (ED) after falling down and being briefly unconsciousness. The patient’s wife is with him and tells the nurse in private, “He’s not been like himself. He’s verbally abusive, now, and mean. He was always the sweetest man I ever knew.” The nurse suspects testing will reveal a lesion in which lobe of the brain?

The patient presents to the emergency department (ED) after cutting off the tip of his middle finger while using a butcher’s knife. Of note, the patient’s vital signs are normal and the patient reports the pain to be a 0 out of 10. The nurse suspects the patient has a lesion in which lobe of the brain?

The patient presents to the clinic for a check-up and is noted to have a temperature of 35.2°C. The patient denies being feeling cold or hot, recent illnesses, or prolonged exposure to the cold. The nurse suspects further testing will reveal a lesion in which area of the brain?

The patient is brought to the emergency department (ED) with sudden onset blindness and deafness. The patient is being guided in by his wife but is walking well. The nurse suspects the patient is experiencing which condition?

The patient is brought to the emergency department (ED) after hitting their head during a fall. The patient does not arouse when their name is called, but opens the eyes and attempts to remove the hand that is pinching him. Once aroused, the patient responds with, “Bubble,” when asked what year it is. The nurse records the patient’s mental status using the Glasgow Coma Scale as which number? Enter your response using a whole number.

Following a motor vehicle accident, the patient is brought via ambulance to the emergency department (ED). The patient is unconscious during the mental status exam. The nurse attempts to arouse the patient by calling her name, but the patient does not respond. Following a firm sternal rub, the patient’s flexes the arms into the chest and moans. The nurse documents the patient’s Glasgow Coma Scale score as which number? Enter your response using a whole number.

The patient’s father is observed pressing the patient’s patient-controlled analgesia (PCA) pump while the patient is asleep. The nurse attempts to arouse the patient, who only opens the eyes after being pinched. Once aroused, the patient is able to raise the hand upon request. When asked what the year is, the patient responds with the previous year. The nurse reports the patient’s condition to the provider with which number on the Glasgow Coma Scale? Enter your response using a whole number.

A decrease in the production of which type of cells may result in thrombocytopenia?

The patient with epilepsy is observed to be staring off into the distance and cannot be aroused from this state for roughly a minute. The nurse documents which type of seizure in the patient?

Which statement is true regarding the neonate's immune system?

The nurse is educating the student nurse on the management of the patient who is mechanically ventilated via an endotracheal tube in the intensive care unit. Which information does the nurse provide to the student nurse?

How many chest compressions per minute are performed during cardiopulmonary resuscitation of the adult?

The patient with chest pain is undergoing an electrocardiogram (ECG). Which ECG finding prompts the activation of the cardiac catheterization lab?

The hospitalized patient is found unresponsive and the cardiopulmonary monitor shows ventricular fibrillation. Upon assessment, no pulse or respiratory effort are appreciated. A code blue is called and the defibrillator is being brought to the room. Which initial intervention is appropriate?