Upon initial assessment of the client with a complete spinal cord injury after a motor vehicle accident, the nurse would expect to observe what finding below the level of injury? 

A client is admitted to the ICU with possible myasthenia gravis crisis. The nurse would consider the placement of which of the following at the bedside to be a priority? 

An ischemic stroke client in the ER has a blood pressure of 179/92, pulse of 104, ICP of 22, and a respiratory rate of 23.  Calculate the cerebral perfusion pressure (CPP) and specify whether this is normal, high, or low. CPP value = This value indicates the CPP is in a/an level.

Due to a motor vehicle accident, the client sustained a traumatic brain injury (TBI) and is intubated and sedated. An intraventricular catheter and external ventricular drain (EVD) were placed in the ICU, as well as a foley catheter. Which findings would warrant immediate action by the nurse?

You are caring for a client in cardiogenic shock admitted to the ICU at 3am status post a right inferior wall myocardial infarction. Which of the following statements are accurate regarding cardiogenic shock? (Select all that apply)

A 47-year-old female client presents to the emergency department with a sudden onset headache. Nursing documentation:1000: The client reports headache pain that came on suddenly stating “it is the worst headache of my life”. Reports taking 650mg of Tylenol prior to coming into the emergency department with no relief. Currently rates her pain 9/10 on a 1-to-10 pain scale and is unable to fully extend her neck. The client is able to move all four extremities against gravity and resistance. She describes experiencing intermittent headaches accompanied by a few episodes of vomiting over the last week. The client has a history of hypertension, dyslipidemia, and a family history of cerebral aneurysms. She is a current smoker and admits to drinking “a few glasses of wine per day.” Vital signs: Temp 98.9, HR 110 (sinus tachycardia), BP 180/93, RR 19, O2 94% on RA

The nurse is preparing to assist with an escharotomy in the burn unit. The nurse is aware that the purpose of an escharotomy is to: 

The nurse is caring for a 17-year-old male involved in a house fire who sustained 2nd and 3rd degree burns to the anterior and posterior aspects of both legs, the entire anterior chest and abdomen, and entire posterior back. Given the burn surface area sustained, determine the percentage of body surface area burned using the Rule of Nines.  %

The nurse is caring for a client who was admitted with a lower GI bleed yesterday. Based on bedside shift report, the nurse suspects that the client is going into hypovolemic shock.  The following assessment data supports the nurse’s concern for hypovolemic shock except:

The nurse is caring for a 30-year-old client who underwent an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Nursing documentation: The client is 7 hours post-op in the intensive care unit. Rates pain a 4 on the 1-to-10 pain scale. Client appears lethargic, but oriented x4 and cooperative. Lungs clear bilaterally. Abdomen is hard and distended. The nurse notes increasing drainage in the client’s abdominal drain.Vital signs are: Temp 98.1, HR 122, BP 89/50, RR 26, O2 94% on RA.