Nursing 202 Exam 3
A nurse is caring for a client who has increased ICP and a new prescription for mannitol
(Osmitrol). For which of the following adverse effects should the nurse monitor?
A.) Hyperglycemia
B.) Hyponatremia
C.) Hypervolemia
D.) Oliguria - answerB.) Hyponatremia
A nurse is caring for a client who has a closed-head injury with ICP readings ranging
from 16-22 mmHg. Which of the following actions should the nurse take to decrease the
potential for raising the client's ICP? (Select all that apply.)
A.) Suction the endotracheal tube.
B.) Hyperventilate the client.
C.) Elevate the client's head on two pillows.
D.) Administer a stool softener.
E.) Keep the client well hydrated. - answerB.) Hyperventilate the client (Hyperventilating
the client will prevent hypercarbia, which can cause vasodilation)
D.) Administer a stool softener (Administration of a stool softener will decrease the need
to bear down (Valsalva maneuver) during bowel movements, which can increase ICP.)
Patient's eyes are open and the patient is speaking to you as you are examining them.
The patient is speaking normally and answering questions appropriately. The patient is
able to follow commands like "show me two fingers". - answerGCS - 15
The patient's eyes remain closed, even if someone calls loudly. However, the patient
will open eyes if pinched. The patient states "don't" or "stop" when pinched, but does
not speak in whole sentences and does not answer any questions. The patient does not
follow any commands, but if pinched, will quickly push the nurse's hand away. -
answerGCS - 10
The patient has their eyes closed at first, but opens them if their name is called loudly.
The patient does not say any recognizable words. When asked a question, the patient
looks confused and says, "mmm?" without opening their mouth. The patient does not
follow commands, but if pinched, they pull away. - answerGCS - 9
Patient's eyes remain closed, even when pinched. The patient does not make any
sounds, even if pinched, and he/she does not follow commands. Finally, the patient will
not moved, even if pinched. - answerGCS - 3
Patient's eyes are open and looking at you while you are examining them. Speech is
clear, but confused. The patient does not know what happened to them and states the
,wrong month when asked the date. The patient is slow to follow commands when asked
to show two fingers, but is still able to do so. - answerGCS - 14
The patient's eyes remain closed, even when pinched. He/she groans in response to
being pinched, but does not say any recognizable words. The patient does not follow
any commands, but if pinched will try to push the nurse's hand away. - answerGCS - 8
The patient's eyes will open and will be looking around with an anxious expression on
their face. The patient will not answer any questions at all. If pinched the patient will
groan, but does not say any recognizable words. The patient does not follow any
commands, but if pinched will quickly push the nurse's hand away. - answerGCS - 11
The patient's eyes will be closed, but will open briefly if someone calls to them loudly.
The patient will not answer any questions. If pinched, the patient will groan or yell, but
does not say any recognizable words. The patient does not follow any commands, but if
pinched will quickly push the nurse's hand away. - answerGCS - 10
The patient's eyes are closed, but will open them if someone speaks to them. The
patient can speak normally, but is confused. The patient does not remember exactly
what happened to them, and gives the wrong month when asked the date. The patient
is slow to follow commands such as, "show me two fingers", but they are able to do so. -
answerGCS - 13
The patient's eyes are closed even if someone talks to them or pinches them. The
patient answers questions correctly. The patient states that "his head hurts". When
asked to open eyes, the patient refuses stating, "the light makes my eyes hurt really
bad." The patient follows commands appropriately, but does not open eyes when doing
so. - answerGCS - 12
A nurse is caring for a client who has just been admitted following surgical evacuation of
a subdural hematoma. Which of the following is the priority assessment?
A.) Glasgow Coma Scale
B.) Cranial nerve function
C.) Oxygen saturation
D.) Pupillary response - answerC.) Oxygen saturation
A nurse is caring for a client who was recently admitted to the emergency department
following a head-on motor vehicle crash. The client is unresponsive, has spontaneous
respirations of 22/min, and has a laceration of his forehead that is bleeding. Which of
the following is the priority nursing action at this time? - answerA.) Keep neck stabilized
A nures in the critical care unit is completing an admission assessment of a client who
has a gunshot wound to the head. Which of the following assessment findings are
indicative of increased ICP? (Select all that apply.)
A.) Headache
B.) Dilated pupils
, C.) Tachycardia
D.) Decorticate posturing
E.) Hypotension - answerA.) Headache
B.) Dilated pupils
D.) Decorticate posturing
A nurse is caring for a client who has diabetes insipidus. Which of the following
urinalysis laboratory findings should the nurse anticipate?
A.) Absence of glucose
B.) Decreased specific gravity
C.) Presence of ketones
D.) Presence of red blood cells (RBCs) - answerC.) Presence of ketones
A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus.
Which of the following statements by the client requires further teaching?
A.) "I can drink up to 2 quarts of fluid a day."
B.) "I should expect to urinate frequently at night."
C.) "I may experience headaches."
D.) "I may experience dry mouth." - answerA.) "I can drink up to 2 quarts of fluid a day."
(Excessive thirst is a manifestation of DI. So, consumption of up to 4-30 liters per day
can be expected and fluid intake should not be limited.)
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH). Which of the following findings should the nurse expect? (Select all that
apply.)
A.) Decreased serum sodium
B.) Urine specific gravity 1.001
C.) Serum osmolality 230 mOsm/L
D.) Polyuria
E.) Increased thirst - answerB.) Urine specific gravity 1.001 (urine of a client with DI will
be dilute with a low specific gravity, so less than 1.005)
A nurse is assessing a client who has SIADH. Which of the following findings indicate
the client is experiencing a complication?
A.) Decreased central venous pressure
B.) Increased urine output
C.) Distended neck veins
D.) Extreme thirst - answerB.) ??
A nurse is caring for a client with diabetes insipidus (DI). Which of the following should
the nurse anticipate? (Select all that apply.)
A.) Hemoconcentration
B.) Dehydration
C.) Hyponatremia
D.) Concentrated urine - answerA.) Hemoconcentration
B.) Dehydration
A nurse is caring for a client who has increased ICP and a new prescription for mannitol
(Osmitrol). For which of the following adverse effects should the nurse monitor?
A.) Hyperglycemia
B.) Hyponatremia
C.) Hypervolemia
D.) Oliguria - answerB.) Hyponatremia
A nurse is caring for a client who has a closed-head injury with ICP readings ranging
from 16-22 mmHg. Which of the following actions should the nurse take to decrease the
potential for raising the client's ICP? (Select all that apply.)
A.) Suction the endotracheal tube.
B.) Hyperventilate the client.
C.) Elevate the client's head on two pillows.
D.) Administer a stool softener.
E.) Keep the client well hydrated. - answerB.) Hyperventilate the client (Hyperventilating
the client will prevent hypercarbia, which can cause vasodilation)
D.) Administer a stool softener (Administration of a stool softener will decrease the need
to bear down (Valsalva maneuver) during bowel movements, which can increase ICP.)
Patient's eyes are open and the patient is speaking to you as you are examining them.
The patient is speaking normally and answering questions appropriately. The patient is
able to follow commands like "show me two fingers". - answerGCS - 15
The patient's eyes remain closed, even if someone calls loudly. However, the patient
will open eyes if pinched. The patient states "don't" or "stop" when pinched, but does
not speak in whole sentences and does not answer any questions. The patient does not
follow any commands, but if pinched, will quickly push the nurse's hand away. -
answerGCS - 10
The patient has their eyes closed at first, but opens them if their name is called loudly.
The patient does not say any recognizable words. When asked a question, the patient
looks confused and says, "mmm?" without opening their mouth. The patient does not
follow commands, but if pinched, they pull away. - answerGCS - 9
Patient's eyes remain closed, even when pinched. The patient does not make any
sounds, even if pinched, and he/she does not follow commands. Finally, the patient will
not moved, even if pinched. - answerGCS - 3
Patient's eyes are open and looking at you while you are examining them. Speech is
clear, but confused. The patient does not know what happened to them and states the
,wrong month when asked the date. The patient is slow to follow commands when asked
to show two fingers, but is still able to do so. - answerGCS - 14
The patient's eyes remain closed, even when pinched. He/she groans in response to
being pinched, but does not say any recognizable words. The patient does not follow
any commands, but if pinched will try to push the nurse's hand away. - answerGCS - 8
The patient's eyes will open and will be looking around with an anxious expression on
their face. The patient will not answer any questions at all. If pinched the patient will
groan, but does not say any recognizable words. The patient does not follow any
commands, but if pinched will quickly push the nurse's hand away. - answerGCS - 11
The patient's eyes will be closed, but will open briefly if someone calls to them loudly.
The patient will not answer any questions. If pinched, the patient will groan or yell, but
does not say any recognizable words. The patient does not follow any commands, but if
pinched will quickly push the nurse's hand away. - answerGCS - 10
The patient's eyes are closed, but will open them if someone speaks to them. The
patient can speak normally, but is confused. The patient does not remember exactly
what happened to them, and gives the wrong month when asked the date. The patient
is slow to follow commands such as, "show me two fingers", but they are able to do so. -
answerGCS - 13
The patient's eyes are closed even if someone talks to them or pinches them. The
patient answers questions correctly. The patient states that "his head hurts". When
asked to open eyes, the patient refuses stating, "the light makes my eyes hurt really
bad." The patient follows commands appropriately, but does not open eyes when doing
so. - answerGCS - 12
A nurse is caring for a client who has just been admitted following surgical evacuation of
a subdural hematoma. Which of the following is the priority assessment?
A.) Glasgow Coma Scale
B.) Cranial nerve function
C.) Oxygen saturation
D.) Pupillary response - answerC.) Oxygen saturation
A nurse is caring for a client who was recently admitted to the emergency department
following a head-on motor vehicle crash. The client is unresponsive, has spontaneous
respirations of 22/min, and has a laceration of his forehead that is bleeding. Which of
the following is the priority nursing action at this time? - answerA.) Keep neck stabilized
A nures in the critical care unit is completing an admission assessment of a client who
has a gunshot wound to the head. Which of the following assessment findings are
indicative of increased ICP? (Select all that apply.)
A.) Headache
B.) Dilated pupils
, C.) Tachycardia
D.) Decorticate posturing
E.) Hypotension - answerA.) Headache
B.) Dilated pupils
D.) Decorticate posturing
A nurse is caring for a client who has diabetes insipidus. Which of the following
urinalysis laboratory findings should the nurse anticipate?
A.) Absence of glucose
B.) Decreased specific gravity
C.) Presence of ketones
D.) Presence of red blood cells (RBCs) - answerC.) Presence of ketones
A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus.
Which of the following statements by the client requires further teaching?
A.) "I can drink up to 2 quarts of fluid a day."
B.) "I should expect to urinate frequently at night."
C.) "I may experience headaches."
D.) "I may experience dry mouth." - answerA.) "I can drink up to 2 quarts of fluid a day."
(Excessive thirst is a manifestation of DI. So, consumption of up to 4-30 liters per day
can be expected and fluid intake should not be limited.)
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH). Which of the following findings should the nurse expect? (Select all that
apply.)
A.) Decreased serum sodium
B.) Urine specific gravity 1.001
C.) Serum osmolality 230 mOsm/L
D.) Polyuria
E.) Increased thirst - answerB.) Urine specific gravity 1.001 (urine of a client with DI will
be dilute with a low specific gravity, so less than 1.005)
A nurse is assessing a client who has SIADH. Which of the following findings indicate
the client is experiencing a complication?
A.) Decreased central venous pressure
B.) Increased urine output
C.) Distended neck veins
D.) Extreme thirst - answerB.) ??
A nurse is caring for a client with diabetes insipidus (DI). Which of the following should
the nurse anticipate? (Select all that apply.)
A.) Hemoconcentration
B.) Dehydration
C.) Hyponatremia
D.) Concentrated urine - answerA.) Hemoconcentration
B.) Dehydration
