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Assessment of a patient with a head injury reveals increased muscle tone and contractured positioning of the upper extremities. A nurse should
See the explanation below.
In patients with head injuries, increased muscle tone and contractured positioning (such as decorticate or decerebrate posturing) are signs of significant neurological impairment. It is essential to manage these symptoms to prevent further complications. Consulting a physical therapist is the best course of action to ensure appropriate positioning, prevent contractures, and manage spasticity effectively. Reference: = CCRN Exam Handbook and AACN's Certification Review Course materials.
A patient was admitted 3 days ago for an overdose of acetaminophen (Tylenol). The patient is developing a decreasing level of consciousness. Which the following is the most likely finding?
See the explanation below.
A patient with acetaminophen overdose is at risk for acute liver failure, which can lead to coagulopathy. This condition is often marked by an increased International Normalized Ratio (INR) due to impaired synthesis of clotting factors in the liver. Decreasing level of consciousness can also result from hepatic encephalopathy, a complication of liver failure. Reference: = CCRN Exam Handbook and AACN's Certification Review Course materials.
Which of the following diagnostic procedures best pinpoints the location, size, and origin of a cerebral aneurysm?
See the explanation below.
Cerebral angiography is considered the gold standard for diagnosing and pinpointing the location, size, and origin of cerebral aneurysms. It involves the use of contrast material injected into the cerebral arteries and imaging to provide detailed visualization of the blood vessels in the brain, which is essential for accurate diagnosis and planning treatment strategies. Reference: = CCRN Exam Handbook and AACN's Certification Review Course materials.
A patient is experiencing lower left quadrant pain with guarding, as well as abdominal distention and rigidity. KUB reveals free air in the abdominal
cavity. Vital signs are:
BP 76/40
HR 130
RR 32
T 101.7 F (38.7C)
A nurse would suspect
See the explanation below.
The clinical presentation of lower left quadrant pain with guarding, abdominal distention, rigidity, and free air in the abdominal cavity on a KUB (kidney, ureter, and bladder) radiograph strongly suggests a perforated bowel. The presence of free air indicates that there is a breach in the gastrointestinal tract, allowing air to escape into the peritoneal cavity. The patient's vital signs, including hypotension (BP 76/40), tachycardia (HR 130), tachypnea (RR 32), and fever (T 101.7F), are consistent with sepsis and shock, which are common complications of bowel perforation. Reference: CCRN Exam Handbook, AACN, page 30, section on Gastrointestinal.
A patient with an acute anterior wall MI presents with an S3 gallop and the following values:
Which drug therapy would be most appropriate for this patient?
See the explanation below.
In the setting of an acute anterior wall myocardial infarction (MI) with an S3 gallop, the patient is likely experiencing heart failure and possibly acute pulmonary edema. The appropriate treatment includes vasodilators to reduce afterload and diuretics to decrease preload and pulmonary congestion. This combination helps to improve cardiac output and reduce the workload on the heart. Reference: CCRN Exam Handbook, AACN, page 20, section on Cardiovascular.
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