Exam 1: Adult

A student nurse rotating in the emergency department overhears the emergency room physician explaining to the client about heart block and mentions the electrical impulse of the heart. Where does the electrical impulse in the heart begin?

A nurse in ICU (intensive care unit) has been assigned to the rapid response team for the day. She is called to the medical surgical floor to the room of a 69 year old woman who was admitted for pneumonia. Her nurse reports that she has been fatigued and difficult to arouse all day, with shallow breathing and restlessness. In the last hour, her blood pressure has risen to 166/88 and her respirations are 30/minute. What does the nurse suspect might have happened?

A 45-year-old woman presents to the emergency department for evaluation of a 12 hour episode of intermittent, debilitating, postprandial right upper quadrant pain associated with nausea and occasional vomiting. The pain can last from 30 minutes to 2 hours, often radiates to the upper back between the shoulder blades, and is not associated with bowel movements or exercise. The patient is also quite jaundiced; however, she denies any fever, weight loss or night sweats. Additionally, she states she has been using antacids and H2-blockers but they have been ineffective. She denies significant alcohol use. What is the most likely diagnosis for this patient?

A nurse is ending his shift and comes in to re-assess his patient, a seventy six year old woman who was diagnosed with a brain lesion. He notes that the patient appears restless and does not know where she is. Upon further examination, he notes that her pupils are sluggish to react to light and are unequal in size. She is unable to sit up at the side of the bed and her blood pressure has risen to 190/88. What does the nurse suspect is occurring?

The nurse is discharging a patient recovering from a respiratory infection. How would the nurse evaluate if the patient understands the most effective ways to prevent infection?

A patient has returned after a lengthy abdominal surgery. The nurse enters the room to assess the patient and observes the patient forcefully coughing without using anything to protect her abdomen. The nurse would teach the patient to use an abdominal pillow over her abdomen when coughing to avoid the post operative complication of:

During the assessment of a patient's heart sounds, the nurse hears a grating sound at the left of the sternal border. It is slightly muffled sounding. What might be the cause of this abnormal heart sound?

A patient with Hemoglobin of 8.2 is receiving an infusion of packed cells. What is the most effective thing the nurse can do to assess for an adverse reaction to the blood?

What signs would be most indicative that Thrombolytic Therapy has been successful in the patient who has had a myocardial infarction and is four hours into Thrombolytic Therapy?

A patient, previously with no heart conditions, is admitted to the intensive care unit for an acute exacerbation of heart failure has an ejection fracture of 28%. He first began experiencing symptoms of heart failure about 6 weeks ago: general tiredness, a dry cough and a weight gain of 12 pounds. What is the most likely cause of the ejection fracture?

Which part of the heart usually shows the signs of deterioration in heart failure?

The nurse is taking care of a 51 year old with Acute Lymphocytic Leukemia (ALL) with a White Blood Cell count of 6.0. What would the nurse NOT do when preventing infection from occurring in the patient?

A patient recovering from a lumbar fusion is experiencing acute pain. What would be an expected outcome for this patient in relation to the acute pain?

You are teaching a new intensive care unit nurse about assessing for acute Tubular Necrosis. What are the hallmark diagnostic tests that reflect the presence of acute Tubular Necrosis?

An experienced intensive care unit nurse is teaching a class of new nurses about the neurological system. What is the best way to describe the purpose of cerebrospinal fluid (CSF) to the class?

Because of the high incidence of myocardial infarctions related to thrombus formation, anticoagulants and Thrombolytic Therapy is considered to be standards of care in the treatment of acute myocardial infarction. When should Thrombolytic Care be started in the patient suspected of having a myocardial infarction?

The nurse is transporting a patient with MRSA to the OR for a shoulder replacement. What precautions regarding infection control should the nurse take?

Guided exposure therapy is usually used for patients with this time of anxiety disorder:

A patient recovering from a myocardial infarction is preparing to transfer to a telemetry floor. The critical care nurse has begun teaching on the Angiotensin converting enzyme inhibitors he will be taking throughout the hospital stay and after discharge. What statement reflects the patient understanding of the medication?

What is one of the biggest concerns as an adverse effect of Thrombolytic Therapy?