A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

Surgery to remove the eye

Referral for drug rehabilitation program

Admission for IV and intravitreal antibiotics

Follow up with eye specialist outpatient

Answer and Explanation

The Correct Answer is C

A. Surgery to remove the eye is not the immediate course of action and is only considered in severe cases where infection cannot be managed.

B. Referral for a drug rehabilitation program is beneficial for the patient's long-term health but is not the priority in this case where there is an active eye infection.

C. Admission for IV and intravitreal antibiotics is necessary to treat a possible severe eye infection, which can be sight-threatening, especially in immunocompromised patients, such as those with a history of IV drug use.

D. An outpatient follow-up with an eye specialist may be part of ongoing care but does not address the acute need for immediate antibiotic therapy to prevent further complications.

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Correct Answer is A

Explanation

A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.

B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.

C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.

D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.

A. T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air B. T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air C. T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air D. T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Correct Answer is B

Explanation

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for several patients in the Intensive Care Unit. Which of the following patients is at greatest risk of anoxic brain injury? A patient who:

Correct Answer is A

Explanation

The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is B

Explanation

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

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The nurse is caring for a patient who has sustained eye trauma as a result of a motor vehicle crash (MVC). Which intervention should the nurse provide regarding a foreign body?

The nurse teaching a patient who is diagnosed with human immunodeficiency virus (HIV), would include which information regarding an activity that has the highest potential to spread the disease to relatives or friends in a household?

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

A patient is ordered 1 mg of Morphine IV push. The medication is supplied in vials 2 mg/1 mL. What should the nurse administer? (round to the nearest tenth)

The provider has prescribed timolol ophthalmic drops for the patient diagnosed with glaucoma. The nurse should assess the patient for which of the following side effects?

The nurse anticipates which antibiotic class, due to the lack of ototoxicity, will be ordered for a patient diagnosed with tympanic membrane rupture?