NUR 390 EXAM 3 QUESTIONS
WITH CORRECT ANSWERS
267 QUESTIONS AND ANSWERS
A 40-yr-old woman who is obese reports that she wants to lose weight. Which
question would the nurse ask first?
a. "What factors led to your weight gain?"
b. "Which types of food do you like best?"
c. "How long have you been overweight?"
d. "What physical activities do you enjoy?"
a. "What factors led to your weight gain?"
Which statement by a patient who is being discharged from the emergency
department (ED) after a concussion indicates a need for intervention by the
nurse?
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go right to bed."
c. "I do not even remember being in an accident today."
d. "I can take acetaminophen (Tylenol) for my headache."
b. "I am going to drive home and go right to bed."
Family members of a patient who has a traumatic brain injury ask the nurse
about the purpose of the ventriculostomy system being used for intracranial
pressure monitoring. Which statement by the nurse would be the best initial
response for this situation?
a. "This is a complex type of monitoring system, and it is managed by skilled
,staff."
b. "The system measures pressures to determine whether blood flow to the brain
is adequate"
c. "The ventriculostomy monitoring system helps check for changes in cerebral
perfusion pressure."
d. "This monitoring system has many benefits, including the ability to drain
cerebrospinal fluid."
b. "The system measures pressures to determine whether blood flow to the brain
is adequate"
Admission vital signs for a patient who has a brain injury are blood pressure of
128/68 mm Hg, pulse of 10 beats/min, and of respirations 26 breaths/min.
Which set of vital signs, if taken 1 hour later, will be of most concern to the
nurse?
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32
breaths/min
c. Blood pressure 148/78 mm Hg, pulse 12 beats/min, respirations 28
breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30
breaths/min
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
When a brain-injured patient responds to nail bed pressure with internal
rotation, adduction, and flexion of the arms, how would the nurse report the
response?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
c. Decorticate posturing
,The nurse has administered prescribed IV mannitol (Osmitrol) to an
unconscious patient. Which parameter would the nurse monitor to determine the
medication's effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
c. Intracranial pressure
A patient with a head injury opens his eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to
push away a painful stimulus. How would the nurse record the patient's
Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
b. 11
An unconscious patient is admitted to the emergency department (ED) with a
head injury. The patient's spouse and teenage children stay at the patient's side
and ask many questions about the treatment. Which action is best for the nurse
to take?
a. Call the family's pastor or spiritual advisor ot take them to the chapel.
b. Ask the family to stay in the waiting room until the assessment is completed.
c. Allow the family to stay with the patient and briefly explain all procedures to
them.
d. Refer the family members to the hospital counseling service to deal with their
anxiety.
c. Allow the family to stay with the patient and briefly explain all procedures to
them.
, A patient who is unconscious after a head injury has cerebral edema. Which
nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
c. Keep the head of the bed elevated to 30 degrees.
A 20-yr-old is admitted with a head injury after a collision while playing sports.
After noting that the patient has developed clear nasal drainage, which action
would the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorthea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.
b. Check the drainage for glucose content.
Which action will the emergency department nurse anticipate for a patient
diagnosed with a concussion who did not lose consciousness?
a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Arrange to admit the patient to the neurologic unit for observation.
d. Transport the patient to radiology for magnetic resonance imaging (MRI).
b. Provide discharge instructions about monitoring neurologic status.
A patient who has a suspected epidural hematoma is admitted to the emergency
department. Which action will the nurse expect to take?
a. Administer IV furosemide (Lasix).
b. Prepare the patient for craniotomy.
c. Initiate high-dose barbiturate therapy.
d. Type and crossmatch for blood transfusion.
b. Prepare the patient for craniotomy.
WITH CORRECT ANSWERS
267 QUESTIONS AND ANSWERS
A 40-yr-old woman who is obese reports that she wants to lose weight. Which
question would the nurse ask first?
a. "What factors led to your weight gain?"
b. "Which types of food do you like best?"
c. "How long have you been overweight?"
d. "What physical activities do you enjoy?"
a. "What factors led to your weight gain?"
Which statement by a patient who is being discharged from the emergency
department (ED) after a concussion indicates a need for intervention by the
nurse?
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go right to bed."
c. "I do not even remember being in an accident today."
d. "I can take acetaminophen (Tylenol) for my headache."
b. "I am going to drive home and go right to bed."
Family members of a patient who has a traumatic brain injury ask the nurse
about the purpose of the ventriculostomy system being used for intracranial
pressure monitoring. Which statement by the nurse would be the best initial
response for this situation?
a. "This is a complex type of monitoring system, and it is managed by skilled
,staff."
b. "The system measures pressures to determine whether blood flow to the brain
is adequate"
c. "The ventriculostomy monitoring system helps check for changes in cerebral
perfusion pressure."
d. "This monitoring system has many benefits, including the ability to drain
cerebrospinal fluid."
b. "The system measures pressures to determine whether blood flow to the brain
is adequate"
Admission vital signs for a patient who has a brain injury are blood pressure of
128/68 mm Hg, pulse of 10 beats/min, and of respirations 26 breaths/min.
Which set of vital signs, if taken 1 hour later, will be of most concern to the
nurse?
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32
breaths/min
c. Blood pressure 148/78 mm Hg, pulse 12 beats/min, respirations 28
breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30
breaths/min
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
When a brain-injured patient responds to nail bed pressure with internal
rotation, adduction, and flexion of the arms, how would the nurse report the
response?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
c. Decorticate posturing
,The nurse has administered prescribed IV mannitol (Osmitrol) to an
unconscious patient. Which parameter would the nurse monitor to determine the
medication's effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
c. Intracranial pressure
A patient with a head injury opens his eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to
push away a painful stimulus. How would the nurse record the patient's
Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
b. 11
An unconscious patient is admitted to the emergency department (ED) with a
head injury. The patient's spouse and teenage children stay at the patient's side
and ask many questions about the treatment. Which action is best for the nurse
to take?
a. Call the family's pastor or spiritual advisor ot take them to the chapel.
b. Ask the family to stay in the waiting room until the assessment is completed.
c. Allow the family to stay with the patient and briefly explain all procedures to
them.
d. Refer the family members to the hospital counseling service to deal with their
anxiety.
c. Allow the family to stay with the patient and briefly explain all procedures to
them.
, A patient who is unconscious after a head injury has cerebral edema. Which
nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
c. Keep the head of the bed elevated to 30 degrees.
A 20-yr-old is admitted with a head injury after a collision while playing sports.
After noting that the patient has developed clear nasal drainage, which action
would the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorthea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.
b. Check the drainage for glucose content.
Which action will the emergency department nurse anticipate for a patient
diagnosed with a concussion who did not lose consciousness?
a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Arrange to admit the patient to the neurologic unit for observation.
d. Transport the patient to radiology for magnetic resonance imaging (MRI).
b. Provide discharge instructions about monitoring neurologic status.
A patient who has a suspected epidural hematoma is admitted to the emergency
department. Which action will the nurse expect to take?
a. Administer IV furosemide (Lasix).
b. Prepare the patient for craniotomy.
c. Initiate high-dose barbiturate therapy.
d. Type and crossmatch for blood transfusion.
b. Prepare the patient for craniotomy.
