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 Question 11 Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion? 1. The patient exhibits facial grimacing to painful stimuli but does not withdrawal from the stimuli. 2. There is bilateral absence of deep tendon reflexes. 3. Laboratory results reveal elevation of creatine kinase level. 4. The patient exhibits diffuse weakness. Question 12 An initiative for early identification of critical illness myopathy has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients? 1. Patients with history of type 1 diabetes mellitus 2. Patients with documented presence of renal calculi 3. Patients admitted with the diagnosis of chronic bronchitis 4. Patents sedated with neuromuscular blocking agents 5. Patients who have received high dose corticosteroid therapy Question 13 The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention? 1. Monitor urine output. 2. Provide eye care. 3. Move the patient as little as possible. 4. Provide mouth care. Question 14 A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication? 1. Fosphenytoin 2. Lorazepam 3. Propofol 4. Diazepam Question 15 A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated? 1. Hold the patient as still as possible to prevent tissue damage. 2. Roll the patient to the side if possible. 3. Place a padded tongue blade in the patient’s mouth. 4. Time the seizure from beginning to end. 5. Call the rapid response team. Question 16 A patient in the critical care unit has a seizure that was determined to be caused by a low blood glucose level. The patient’s blood glucose level is currently normal. Which additional intervention should be implemented to prevent future seizure activity in this patient? 1. Administer valium orally twice each day. 2. Establish a low-dose continuous phenytoin infusion. 3. Increase the frequency of blood glucose assessment. 4. Frequently monitor brain wave activity. Question 17 A patient in the intensive care unit continues to seizure after receiving lorazepam. He currently has an intravenous infusion of dextrose 5% and 0.45 normal saline infusing at a rate of 125 mL/hr. The nurse would anticipate providing which medication? 1. Fosphenytoin 2. Phenytoin and diazepam 3. Haloperidol 4. Additional lorazepam Question 18 A patient with seizure activity is receiving intravenous phenytoin (Dilantin). Which nursing interventions are indicated? 1. Assess deep tendon reflexes. 2. Keep blood glucose level within normal limits. 3. Monitor injection site frequently. 4. Turn and reposition every hour. 5. Monitor for the development of hypotension. Question 19 A patient newly admitted to the intensive care unit reports that he has not been sleeping well at home. The nurse would conduct assessment for which preexisting conditions? 1. Taking a beta blocker 2. Use of a bronchodilator 3. Snoring 4. Hypothyroidism 5. Alcoholism Question 20 A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use. Before administering this drug the nurse should prepare to manage which patient response? 1. Hypertension 2. Seizure 3. Sudden temperature elevation 4. Bradycardia