1. A woman is consulting with her nurse reguarding losing weight. She is concerned about what an appropriate weight loss per week would be. The nurse responds by saying:
A. "You can lose as much weight a week as you feel is needed"
B. "The amount of weight loss per week is based soley on your BMI"
C. "As long as you are physically active it doesn't matter how much weight you lose per week"
D. "Along with a diet that is individually planned, a weight loss of 1-2 lbs. per week is appropriate"
Answer: D
2. Nurse Mary is assessing a patient who has suffered a recent head injury. He is Alert to time, person, and place, but it takes him a considerable amount of time to answer. The patient sleeps most of the day. Based on this information the patient is considered:
A. Lethargic
B. Obtunded
C. Confused
D. Stuporous
Answer: A
3. A patient has confirmed diagnosis of increased intracranial pressure. Which of the following diagnostic tests should the nurse question:
A. MRI
B. CT
C. Serum osmolality
D. Lumbar puncture
Answer: D
4. A patient with IICP has an intraventricular catheter inserted into the lateral ventricle. Which of the following statements indicates understanding of this method of monitoring ICP:
A. "An Intraventricular catheter has the ability to drain CSF while also measuring ICP"
B. "The intraventricular catheter dressing only needs to be changed 1 time per week"
C. "An intraventricular catheter is the least invasive method of monitoring"
D. "It is the most immediate method of monitoring ICP"
Answer: A
5.A patient with IICP is ventilated upon admission to the ER following a motor vehicle accident. Ventilation works by:
A. Promoting cerebral vasoconstriction
B. Increasing PaCO2
C. Decreasing the amount of O2
D. Decreasing the risk of seizure activity
Answer: A
Perfusion
I: Change patient position hourly and avoid crossing legs
R: Chaning position helps circulation through the body and keeping the legs uncrossed allows increased circulation to the lower extremities
I:Promote relaxation and ways to reduce stress(relaxation techniques)
R: Stress increases vasoconstriction, altering circulation
I:Assess and record strength of pulses
R:A deficit in or the report of weakened pulses is an indicator of impaired circulation
Cellular Regulation:
I:Weigh client routinely
R:Weight loss is a common manifestation noted in patients who are undergoing treatment of cancer
I:Monitor lab values: CBC with diff, platelets, BUN, liver enzymes
R: The patient with cancer is at increased risk of infection due to immunosuppression. Monitoring lab values can show a sign of early infection
I:Encourage client to express feelings concerning altered body image
R: Patient with cancer may experience loss of body part, weight loss, and alopecia r/t chemotherapy; medication side effects
A patient with an INR of 4 would be on Coumadin.
I:Stress the importance of routine lab work
R:Coumadin should be kept in a theraputic range of 2-3. Labs will be an indicator as to whether levels should be adjusted.
I:Administer medication at the same time everyday, per doctor's order
R:Taking the medication at the same time will maintain a consistent level and prevent deviance from the theraputic range.
I:Shave patient using electric razor
R:Using an electric razor will decrease chances of cutting the patient, thus decreasing the risk of bleeding.
A. "You can lose as much weight a week as you feel is needed"
B. "The amount of weight loss per week is based soley on your BMI"
C. "As long as you are physically active it doesn't matter how much weight you lose per week"
D. "Along with a diet that is individually planned, a weight loss of 1-2 lbs. per week is appropriate"
Answer: D
2. Nurse Mary is assessing a patient who has suffered a recent head injury. He is Alert to time, person, and place, but it takes him a considerable amount of time to answer. The patient sleeps most of the day. Based on this information the patient is considered:
A. Lethargic
B. Obtunded
C. Confused
D. Stuporous
Answer: A
3. A patient has confirmed diagnosis of increased intracranial pressure. Which of the following diagnostic tests should the nurse question:
A. MRI
B. CT
C. Serum osmolality
D. Lumbar puncture
Answer: D
4. A patient with IICP has an intraventricular catheter inserted into the lateral ventricle. Which of the following statements indicates understanding of this method of monitoring ICP:
A. "An Intraventricular catheter has the ability to drain CSF while also measuring ICP"
B. "The intraventricular catheter dressing only needs to be changed 1 time per week"
C. "An intraventricular catheter is the least invasive method of monitoring"
D. "It is the most immediate method of monitoring ICP"
Answer: A
5.A patient with IICP is ventilated upon admission to the ER following a motor vehicle accident. Ventilation works by:
A. Promoting cerebral vasoconstriction
B. Increasing PaCO2
C. Decreasing the amount of O2
D. Decreasing the risk of seizure activity
Answer: A
Perfusion
I: Change patient position hourly and avoid crossing legs
R: Chaning position helps circulation through the body and keeping the legs uncrossed allows increased circulation to the lower extremities
I:Promote relaxation and ways to reduce stress(relaxation techniques)
R: Stress increases vasoconstriction, altering circulation
I:Assess and record strength of pulses
R:A deficit in or the report of weakened pulses is an indicator of impaired circulation
Cellular Regulation:
I:Weigh client routinely
R:Weight loss is a common manifestation noted in patients who are undergoing treatment of cancer
I:Monitor lab values: CBC with diff, platelets, BUN, liver enzymes
R: The patient with cancer is at increased risk of infection due to immunosuppression. Monitoring lab values can show a sign of early infection
I:Encourage client to express feelings concerning altered body image
R: Patient with cancer may experience loss of body part, weight loss, and alopecia r/t chemotherapy; medication side effects
A patient with an INR of 4 would be on Coumadin.
I:Stress the importance of routine lab work
R:Coumadin should be kept in a theraputic range of 2-3. Labs will be an indicator as to whether levels should be adjusted.
I:Administer medication at the same time everyday, per doctor's order
R:Taking the medication at the same time will maintain a consistent level and prevent deviance from the theraputic range.
I:Shave patient using electric razor
R:Using an electric razor will decrease chances of cutting the patient, thus decreasing the risk of bleeding.