NUR 2243 STUDY GUIDE 2026 COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
◉A nurse cares for a client with a burn injury who presents with
drooling and difficulty swallowing. Which action should the nurse take
first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds. Answer:
ANS: C
Inhalation injuries are present in 7% of clients admitted to burn centers.
Drooling and difficulty swallowing can mean that the client is about to
lose his or her airway because of this injury. Absence of breath sounds
over the trachea and bronchi indicates impending airway obstruction and
demands immediate intubation. Knowing the level of consciousness is
important in assessing oxygenation to the brain. Ascertaining the time of
last food intake is important in case intubation is necessary (the nurse
will be more alert for signs of aspiration). However, assessing for air
exchange is the most important intervention at this time. Measuring
abdominal girth is not relevant in this situation.
◉The nurse is caring for a patient with increased intracranial pressure.
Which action is considered unsafe?
a. Aligning the neck with the body
,b. Clustering many nursing activities
c. Elevating the head of the bed 30 degrees
d. Providing stool softeners or laxatives as ordered Answer: ANS: B
It is important to minimize stress and activities that could increase
intracranial pressure. Combining many nursing activities could increase
oxygen demand and intracranial pressure. This would not be safe.
Interventions which can promote venous outflow can help decrease
intracranial pressure. The stress of constipation or bowel movements can
increase intracranial pressure; stool softeners or laxatives can minimize
this.
◉The earliest and most sensitive assessment finding that would indicate
an alteration in intracranial regulation would be
a. change in level of consciousness.
b. inability to focus visually.
c. loss of primitive reflexes.
d. unequal pupil size. Answer: ANS: A
A change in level of consciousness is the earliest and most sensitive
indication of a change in intracranial processing. This is assessed with
the Glasgow Coma Scale (GCS), which assesses eye opening and verbal
and motor response. The inability to focus may indicate a change, but it
is not one of the earliest indicators or a component of the GCS. Primitive
reflexes refers to those reflexes found in a normal infant that disappear
with maturation. These reflexes may reappear with frontal lobe
dysfunction and may be tested for with a suspected brain injury, so it
would be the reappearance of primitive reflexes. A change in pupil size
,or unequal pupils may indicate a change, but they are not one of the
earliest indicators or a component of the GCS.
◉When caring for the patient after a head injury, the nurse would be
most concerned with assessment findings which included respiratory
changes,
a. hypertension, and bradycardia.
b. hypertension, and tachycardia.
c. hypotension, and bradycardia.
d. hypotension, and tachycardia. Answer: ANS: A
Hypertension with widening pulse pressure, bradycardia, and respiratory
changes are the ominous late signs of increased intracranial pressure and
indications of impending herniation (Cushings triad). It is bradycardia,
not tachycardia, which is the component of this ominous triad. It is
hypertension, not hypotension, which is the component of this ominous
triad.
◉Components of the GCS the nurse would use to assess a patient after a
head injury include
a. blood pressure.
b. cranial nerve function.
c. head circumference.
d. verbal responsiveness. Answer: ANS: D
Components of the GCS include eye opening, motor responsiveness, and
verbal responsiveness. The nurse would want to assess the blood
, pressure, but this is not a component of the coma scale. Assessment of
cranial nerve function is appropriate as alterations such as cranial nerve
VI palsies may occur, but this is not part of the coma scale. Increases in
head circumference are associated with alterations in intracranial
pressure in infants, but this is not part of the coma scale.
◉Primary prevention strategies to reduce the occurrence of head injuries
would include
a. blood pressure control.
b. smoking cessation.
c. maintaining a healthy weight.
d. violence prevention. Answer: ANS: D
Injury prevention measures such as wearing a seat belt, helmet use,
firearm safety, and violence prevention programs reduce the risk of
traumatic brain injuries. Blood pressure control and exercising can
decrease the risk of vascular disease, impacting the cerebral arteries,
rather than head injuries. Smoking cessation is one primary prevention
strategy which can decrease the risk of vascular disease. Maintaining a
healthy weight can decrease the risk of vascular disease.
◉The nurse preparing to care for a patient after a suspected stroke
would question an order for a(n)
a. antihypertensive
b. antipyretic
c. osmotic diuretic
QUESTIONS AND VERIFIED SOLUTIONS
◉A nurse cares for a client with a burn injury who presents with
drooling and difficulty swallowing. Which action should the nurse take
first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds. Answer:
ANS: C
Inhalation injuries are present in 7% of clients admitted to burn centers.
Drooling and difficulty swallowing can mean that the client is about to
lose his or her airway because of this injury. Absence of breath sounds
over the trachea and bronchi indicates impending airway obstruction and
demands immediate intubation. Knowing the level of consciousness is
important in assessing oxygenation to the brain. Ascertaining the time of
last food intake is important in case intubation is necessary (the nurse
will be more alert for signs of aspiration). However, assessing for air
exchange is the most important intervention at this time. Measuring
abdominal girth is not relevant in this situation.
◉The nurse is caring for a patient with increased intracranial pressure.
Which action is considered unsafe?
a. Aligning the neck with the body
,b. Clustering many nursing activities
c. Elevating the head of the bed 30 degrees
d. Providing stool softeners or laxatives as ordered Answer: ANS: B
It is important to minimize stress and activities that could increase
intracranial pressure. Combining many nursing activities could increase
oxygen demand and intracranial pressure. This would not be safe.
Interventions which can promote venous outflow can help decrease
intracranial pressure. The stress of constipation or bowel movements can
increase intracranial pressure; stool softeners or laxatives can minimize
this.
◉The earliest and most sensitive assessment finding that would indicate
an alteration in intracranial regulation would be
a. change in level of consciousness.
b. inability to focus visually.
c. loss of primitive reflexes.
d. unequal pupil size. Answer: ANS: A
A change in level of consciousness is the earliest and most sensitive
indication of a change in intracranial processing. This is assessed with
the Glasgow Coma Scale (GCS), which assesses eye opening and verbal
and motor response. The inability to focus may indicate a change, but it
is not one of the earliest indicators or a component of the GCS. Primitive
reflexes refers to those reflexes found in a normal infant that disappear
with maturation. These reflexes may reappear with frontal lobe
dysfunction and may be tested for with a suspected brain injury, so it
would be the reappearance of primitive reflexes. A change in pupil size
,or unequal pupils may indicate a change, but they are not one of the
earliest indicators or a component of the GCS.
◉When caring for the patient after a head injury, the nurse would be
most concerned with assessment findings which included respiratory
changes,
a. hypertension, and bradycardia.
b. hypertension, and tachycardia.
c. hypotension, and bradycardia.
d. hypotension, and tachycardia. Answer: ANS: A
Hypertension with widening pulse pressure, bradycardia, and respiratory
changes are the ominous late signs of increased intracranial pressure and
indications of impending herniation (Cushings triad). It is bradycardia,
not tachycardia, which is the component of this ominous triad. It is
hypertension, not hypotension, which is the component of this ominous
triad.
◉Components of the GCS the nurse would use to assess a patient after a
head injury include
a. blood pressure.
b. cranial nerve function.
c. head circumference.
d. verbal responsiveness. Answer: ANS: D
Components of the GCS include eye opening, motor responsiveness, and
verbal responsiveness. The nurse would want to assess the blood
, pressure, but this is not a component of the coma scale. Assessment of
cranial nerve function is appropriate as alterations such as cranial nerve
VI palsies may occur, but this is not part of the coma scale. Increases in
head circumference are associated with alterations in intracranial
pressure in infants, but this is not part of the coma scale.
◉Primary prevention strategies to reduce the occurrence of head injuries
would include
a. blood pressure control.
b. smoking cessation.
c. maintaining a healthy weight.
d. violence prevention. Answer: ANS: D
Injury prevention measures such as wearing a seat belt, helmet use,
firearm safety, and violence prevention programs reduce the risk of
traumatic brain injuries. Blood pressure control and exercising can
decrease the risk of vascular disease, impacting the cerebral arteries,
rather than head injuries. Smoking cessation is one primary prevention
strategy which can decrease the risk of vascular disease. Maintaining a
healthy weight can decrease the risk of vascular disease.
◉The nurse preparing to care for a patient after a suspected stroke
would question an order for a(n)
a. antihypertensive
b. antipyretic
c. osmotic diuretic
