1.
A 47-year-old male has been admitted to the CCU from the emergency room with a history of sudden diaphoresis, nausea, vomiting and radiating pain down his left arm. He reports no significant medical history, and has been a two PPD smoker since his early twenties. His admitting diagnosis is UA/NSTEMI and he is being prepped for cardiac catheterization for possible angioplasty with stent placement. What type of medication orders might the nurse see prior to his procedure?
a. Clopidogrel and ASA
b. Clopidogrel and prasugrel
c. Clopidogrel and meperidine
d. Prasugrel, ASA, and hyoscyamine
In 2011, a joint task force of the American College of Cardiology Foundation and the American Heart Association published updated guidelines for the treatment of unstable angina (UA) with non-ST elevation myocardial infarction (NSTEMI). These guidelines recommend that all patients with this diagnosis receive ASA on admission, and throughout hospitalization, if tolerated. If a patient is scheduled for percutaneous coronary intervention (PCI), it is recommended that a second anti-platelet therapy be added, such as clopidogrel (Plavix).
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2.
A 62-year-old male presents to the emergency department with complaints of sudden onset chest pain, shortness of breath, and dizziness. The nurse places the client on a cardiac monitor and notes the attached rhythm. Which intervention is most appropriate for this client?
a. Initiate CPR
b. Put ice to client's face
c. Synchronized cardioversion
d. Administer atropine
The client's heart rhythm demonstrates ventricular fibrillation. Ventricular fibrillation is an arrythmia that occurs in the bottom chambers of the heart and can be life threatening. Symptoms include chest pain, dyspnea, nausea, dizziness, palpitations, and hypotension. It requires immediate intervention and cardiopulmonary resuscitation should be started immediately. Putting ice to the client's face is the appropriate intervention for a client who is experiencing supraventricular tachycardia. Synchronized cardioversion is the appropriate intervention for a client who is experiencing atrial fibrillation, atrial flutter, or atrial tachycardia. Atropine is a medication used for symptomatic bradycardia. Image by Antoine Ayer, CC BY-SA 4.0 , via Wikimedia Commons.
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5.
Agnes is a 65-year-old white female who has a history of pulmonary fibrosis with steroid use for the past two years with concomitant hypertension. She has been on oxygen therapy at 4L per nasal cannula for the past 3 years. Recently, her first great-grandchild was born, and she decided to quit smoking. Three days ago, she experienced nausea and dizziness and was admitted to the CCU with a diagnosis of acute myocardial infarction. During shift change, Agnes' low blood pressure alarm sounds. Upon assessment, she is diaphoretic and has severe dyspnea. What is the most likely cause of her symptoms?
a. Exacerbation of pulmonary fibrosis
b. Pulmonary embolism
c. Recurrent myocardial infarction
d. Papillary muscle rupture
Myocardial rupture can be a catastrophic sequelae of acute myocardial infarction. It can occur in several sites in the heart after AMI, including the left papillary muscle. This event typically occurs 3-5 days after the AMI has occurred, and is more common in women who have a history of hypertension and are over the age of 60. The posteromedial papillary muscle is twice as likely to rupture as the anterolateral papillary muscle, due to the additional blood supply to the latter. Symptoms may include hypotension, shortness of breath, acute pulmonary edema and shock. Generally, mitral valve replacement is the most effective treatment.
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Refer to the following for questions 6 and 7:
Norman is a 65 year old paraplegic who resides in a nursing home. He presents with a 3-day history of increased temperature, productive cough, and increased weakness. His caregiver states that he had developed a decubitis ulcer, and has not been able to tolerate sitting in his wheelchair, so has been in bed for the past week. Bibasilar crackles are audible on auscultation, with overall diminished breath sounds bilaterally. Obvious respiratory distress is apparent with tachypnea, suprasternal retractions and use of accessory muscles. Vitals: T-100.2F, HR-120, RR-28, BP 104/50, O2 Sat on RA - 88%. An initial chest x-ray reveals the "spine sign" and a normal cardiac silhouette.
14.
Which lab findings would be seen in a client who presents with syndrome of inappropriate antidiuretic hormone secretion?
a. Urine osmolality decreased, serum osmolality is increased, sodium is normal
b. Urine osmolality is decreased, serum osmolality is decreased, sodium is low
c. Urine osmolality increased, serum osmolality is decreased, sodium is high
d. Urine osmolality is increased, serum osmolality is increased, sodium is normal
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs when there is a large release of vasopressin which causes hyponatremia, decreased urine osmolality and decreased serum osmolality. Client's will have a decreased urine output due to concentrated urine production. Diabetes insipidus causes decreased urine osmolality, increased serum osmolality and a normal to high sodium level.
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17.
A 45-year-old client is admitted for severe anemia secondary to chemotherapy. The nurse started the client's blood transfusion approximately 1 hour ago. The nurse is assessing vital signs and notes a heart rate of 162 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 84/58 mm Hg, and temperature of 101.5 degrees F. The client is vomiting and has severe agitation. Which type of transfusion reaction is this client most likely experiencing?
a. Allergic transfusion reaction
b. Acute hemolytic transfusion reaction
c. Transfusion-associated circulatory overload
d. Septic transfusion reaction
Acute hemolytic transfusion reactions occur within twenty-four hours of transfusion and occurs when there is incompatibility between the receipt and donor's blood. This incompatibility causes a systemic inflammatory response. Symptoms include tachycardia, hypotension, fever, nausea and vomiting, agitation, flank pain, and hemoglobinuria. An allergic transfusion reaction occurs when a client has an allergic reaction to the blood and symptoms include hives and pruritus. Transfusion-associated circulatory overload symptoms include dyspnea, pulmonary edema, and cough. Septic transfusion reaction symptoms include fever, disseminated intravascular coagulation, hypotension, and organ failure.
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18.
A 55-year-old male has a history of lymphoma and has been receiving chemotherapy treatment for the past 3 months. The client presents to the emergency department with concerns for weakness, nausea, and decreased urine output. Labs include a potassium of 6.9 mmol/L, phosphate of 8.9 mg/dL, uric acid of 12.4 mg/dL, creatinine of 2.3 mg/dL, and calcium of 7.7 mg/dL. Which intervention is priority given the client's assessment and lab results?
a. Administer calcium supplement
b. Administer allopurinol
c. Administer rapid volume expansion with normal saline
d. Administer recombinant urate oxidase
The client is presenting with signs and symptoms of tumor lysis syndrome which is a complication of chemotherapy. Tumor lysis syndrome occurs when cancer cells die and are released into the bloodstream causing severe electrolyte imbalances such as hyperkalemia, hyperphosphatemia, and hypocalcemia. The first priority is to administer normal saline to prevent complications such as renal damage and help correct electrolyte imbalances. Normal saline helps to dilute uric acid and promote excretion. Administering calcium supplements, allopurinol, and recombinant urate oxidase are treatments used for tumor lysis syndrome but are not the initial priority.
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19.
Which lab findings would be seen in a client who presents with disseminated intravascular coagulation?
a. INR 0.8, PTT 28, fibrinogen 250
b. INR 1.4, PTT 37, fibrinogen 340
c. INR 0.3, PTT 30, fibrinogen 650
d. INR 4.2, PTT 47, fibrinogen 50
Disseminated intravascular coagulation occurs when there is an excess of thrombin which can cause an increased INR, increased PTT, increased d-dimer, and decreased fibrinogen. A normal INR is less than or equal to 1.1, a normal PTT is 25-35 seconds, and a normal fibrinogen is 200-400 mg/dL. Thrombotic thrombocytopenia purpura occurs when there is an endothelial defect which can cause a normal to slightly increased INR, a normal to slightly increased PTT, a normal fibrinogen, and slightly increased d-dimer. Immune thrombocytopenia occurs when there are anti-platelet antibodies. Clients presenting with ITP will have normal labs.
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25.
Donna is a 43-year-old teacher who was admitted 6 days ago with a ruptured middle cerebral artery (MCA) aneurysm with subarachnoid hemorrhage (SAH). She underwent surgery for aneurysm clipping 12 hours after admission, and has had an excellent post-operative course. However, this morning, she complained of a severe headache, became acutely confused and quickly progressed to unresponsiveness. What is the likely cause for Donna's change of status?
a. Expansion of her original SAH
b. Uncal herniation
c. Cerebral vasospasm
d. Medication reaction
Donna is most likely experiencing vasospasm of one or more of her cerebral arteries. When this occurs, it is generally within 4-14 days for patients who have never had a cerebral bleed in the past, and sooner if this bleed is a recurrence. Usually, the site of spasm is unrelated to the site of rupture. Vasospasm is a serious complication, as it can lead to impaired cerebral autoregulation, cerebral ischemia, and infarction.
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Refer to the following for questions 32 and 33:
A 62-year-old male with a past medical history of hypertension and type 2 diabetes mellitus presents to the emergency department with concerns for decreased urine output, fatigue, and edema in lower extremities for the past week. Vital signs include a heart rate of 92 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 160/90 mmHg and temperature of 98.7 degrees F. Labs include a serum creatinine of 4.6 mg/dL, potassium of 6.5 mmol/L, sodium 136 mmol/L, and blood urea nitrogen of 52 mg/dL. Urinalysis shows 3+ proteinuria, 1+ hematuria, and elevated specific gravity.
36.
A 22-year-old client presents to the emergency department with concerns for tremors, confusion and agitation. The client has a history of major depressive syndrome and was recently started on a new antidepressant medications. Vital signs include a heart rate of 120 beats per minute, respiratory rate of 24 breaths per minute, blood pressure of 150/90 mmHg, and temperature of 103.2 degrees F. On examination, client has 4+ reflexes and muscle rigidity. Labs include a normal basic metabolic panel, normal electrolytes, and an elevated serum creatinine kinase. Which intervention is most appropriate for this client?
a. Discontinue serotonergic medication
b. Administer lorazepam
c. Initiate therapeutic hypothermia protocol
d. Administer haloperidol
The client is presenting with serotonin syndrome which occurs when there is an excess amount of serotonin in the body. This can be caused by taking selective serotonin reuptake inhibitors for mental health illnesses. Symptoms include tremors, confusion, agitation, hyperreflexia, muscle rigidity, increased temperature, and tachycardia. The priority intervention is to discontinue the serotonergic medications to prevent worsening symptoms.
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37.
A 6-month-old infant presents to the emergency department with concerns for poor feedings, emesis, and a seizure-like episode. Vital signs include a heart rate of 162 beats per minute, respiratory rate of 30 breaths per minute, blood pressure of 90/60 mmHg, and temperature of 100.8 degrees F. The infant is lethargic with poor muscle tone. Which assessment finding is diagnostic for a child who presents with shaken baby syndrome?
a. Pulsating anterior fontanelle
b. Postauricular ecchymosis
c. Hemotympanum
d. Retinal hemorrhages
Shaken baby syndrome occurs when a child has been shaken which leads to serious brain injuries. Symptoms include irritability, emesis, poor feedings, lethargy, and seizures. A hallmark sign of shaken baby syndrome includes retinal hemorrhages which is caused by the force of shaking breaking the blood vessels in the eye. Pulsating anterior fontanelle, postauricular ecchymosis, and hemotympanum can be seen in a child with head trauma but is not specific to shaken baby syndrome.
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39.
Andrew is a 47-year-old with advanced amyotrophic lateralizing sclerosis (ALS). He requires total assistance for positioning, bathing and mobility. His swallowing is impaired, so he takes nothing by mouth and receives nutrition through tube feedings via a gastrostomy tube. Based on his current condition, what type of asphyxia may Andrew be most susceptible to?
a. Cardiac asphyxia
b. Neurological asphyxia
c. Foreign body asphyxia
d. Positional asphyxia
Due to his weakness and inability to position himself, Andrew is susceptible to positional asphyxia. Positional asphyxia is associated with compromised respiratory function due to external factors which impair chest expansion, or create occlusion of the upper airway due to abnormal body position. Victims of positional asphyxia are unable to remove themselves from situations which compromise their respiratory status for various reasons, including cognitive and coordination impairment due to intoxication, sedation, neurological abnormalities, impaired consciousness, physical impairment or restraint.
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Refer to the following for questions 40 and 41:
A 30-year-old underwent an emergency cesarean section secondary to placental abruption. The client is now in the postpartum unit. Upon assessment, the nurse notes the client has an altered mental status, dyspnea, and cyanosis. Vital signs include a respiratory rate of 45 breaths per minute, heart rate of 138 beats per minute, and blood pressure of 64/40 mm Hg.
45.
Jerry is a 55-year-old veteran who has been admitted after a motor vehicle accident with multiple injuries. His friend reported that he had been using synthetic marijuana prior to the accident, and that he also sees a psychiatrist at the VA hospital for an unknown diagnosis. He stated that Jerry sometimes gets "hyper" for no reason, starts "ranting" and becomes violent. Of the following, which general psychiatric disorder is characterized by a pattern of aggression or violence which includes irritability, agitation, and violent behavior during manic or psychotic episodes?
a. Schizophrenia
b. Post-traumatic stress disorder (PTSD)
c. Bipolar disorder
d. Delusional disorder
The pattern of aggression or violence of bipolar disorder includes irritability, agitation, and violent behavior during manic or psychotic episodes, which is highly co-morbid with substance use, which worsens the prognosis. The Diagnostic and Statistical Manual of Mental Disorders identifies several disorders which may carry a higher risk for violent and/or aggressive behaviors, which is a concern when patients with co-morbid psychiatric disorders are admitted to the ICU or general floor for medical-surgical needs.
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