NUR 265 EXAM 3 WITH 100% CORRECT
AND VERIFIED ANSWERS (RATIONALE)
NUR MED SURG (GALEN COLLEGE OF
NURSING)
vendarsol
, 1
EXAM 3 Practice Questions NUR
265
Unit 7 Complex Mobility, Sensation, and
Cognition Unit 8 Shock, Tissue Integrity
(BURNS)
1.) The nurse is caring for an adult client who was recently admitted
with a head injury following a motor vehicle crash. One hour ago, the
client's vital signs (VS) were temperature (T): 98.6° F; pulse (P): 110;
respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of the
following findings is a priority for the nurse to follow up?
P: 90; R: 32; BP: 130/72 mm
Hg.- P: 120; R: 26, BP: 110/70
mm_ Hg. P: 56; R: 14; BP:
166/52 mm Hg.
P: 64, R: 30; BP: 148/78m Hg.
2.) The nurse is caring for a client who sustained a closed head injury, is
receiving mechanical ventilation, and is at risk for developing increased
intracranial pressure (ICP). Which of the following actions should the
nurse take when caring for this client?
Perform passive range of motion (ROM) to the client's hips and
knees. Log roll the client during turning and repositioning.
Elevate the foot of the client's bed.
Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
3.) The newly hired nurse is caring for a client who was admitted 12
hours ago with a traumatic brain injury (TBI), is intubated, and is at
risk for developing increased intracranial pressure (ICP).
Which interventions from the box below should the nurse include in
the client's plan of care?
1 Avoid clustering client care activities.
2 Maintain the head in a flexed position.
3 Provide a quiet environment by limiting visitors.
4 Have the client cough and deep breathe every hour.
5 Hyper oxygenate the client before and after suctioning.
6. Avoid maintaining hips in a flexed position.
1, 3, 4, 5.
1, 3, 5, 6.
1, 2, 4, 6.
2, 4, 6.
4.) The nurse working in the intensive care unit (ICU) is assessing a
client who sustained a basilar skull fracture 24 hours ago. It is most
important to follow up with the primary health care provider (PHCP) if
the client
becomes irritable and
restless. has bruises under
the eyes.
is unable to name the state capital.
, 2
reports having a persistent headache since admission.
, 3
5.) The nurse is assessing a client who has experienced a mild
traumatic brain injury (TBI). Which findings from the box below are
consistent with this diagnosis?
1 Dizziness and gait problems.
2 A widened pulse pressure.
3 Increased sensitivity to light or noise.
4 A Glasgow Coma Scale (GCS) score of 9.
5 Dilated pupils that are nopreactive to light.
6 Amnesia about the events around the time of injury.
1, 3, 6.
3, 5, 6.
2, 3, 4, 5.
1, 2, 4, 6.
6.) The nurse is providing discharge instructions to the parents of
a 15-year-old female who sustained a concussion while plaving
field back
Which of the following statements by a parent indicates a need for
further teaching?
"We should avoid giving any acetaminophen to treat headaches.
"We need to bring our daughter back te the emergency department if she exhibits
blurred vision."
"We should provide a consistent routine at home to assist with any behavior
changes." "We will not allow our daughter to engage in strenuous activity for
at least 48 hours."
7.) The nurse is assessing clients for the risk of sustaining a
traumatic brain injury (TBI). Which of the following clients should
the nurse identify as being at greatest risk?
45-year-old who has epilepsy and takes phenytoin.
75-year-old who lives alone and has macular degeneration.
7-year-old who is learning how to ride a bicycle without training
wheels. 20-year-old college student who participates on the
tennis team.
8.) The nurse is providing discharge instructions to the partner of
a client who sustained a mild head injury as a result of a motor
vehicle crash. Which of the following statements by a partner
indicates a need for farther teaching?
"It is expected that my partner will have drainage from the nose for the next
few days." "I will provide my partner with aeetaminophen every 4 hours for
AND VERIFIED ANSWERS (RATIONALE)
NUR MED SURG (GALEN COLLEGE OF
NURSING)
vendarsol
, 1
EXAM 3 Practice Questions NUR
265
Unit 7 Complex Mobility, Sensation, and
Cognition Unit 8 Shock, Tissue Integrity
(BURNS)
1.) The nurse is caring for an adult client who was recently admitted
with a head injury following a motor vehicle crash. One hour ago, the
client's vital signs (VS) were temperature (T): 98.6° F; pulse (P): 110;
respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of the
following findings is a priority for the nurse to follow up?
P: 90; R: 32; BP: 130/72 mm
Hg.- P: 120; R: 26, BP: 110/70
mm_ Hg. P: 56; R: 14; BP:
166/52 mm Hg.
P: 64, R: 30; BP: 148/78m Hg.
2.) The nurse is caring for a client who sustained a closed head injury, is
receiving mechanical ventilation, and is at risk for developing increased
intracranial pressure (ICP). Which of the following actions should the
nurse take when caring for this client?
Perform passive range of motion (ROM) to the client's hips and
knees. Log roll the client during turning and repositioning.
Elevate the foot of the client's bed.
Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
3.) The newly hired nurse is caring for a client who was admitted 12
hours ago with a traumatic brain injury (TBI), is intubated, and is at
risk for developing increased intracranial pressure (ICP).
Which interventions from the box below should the nurse include in
the client's plan of care?
1 Avoid clustering client care activities.
2 Maintain the head in a flexed position.
3 Provide a quiet environment by limiting visitors.
4 Have the client cough and deep breathe every hour.
5 Hyper oxygenate the client before and after suctioning.
6. Avoid maintaining hips in a flexed position.
1, 3, 4, 5.
1, 3, 5, 6.
1, 2, 4, 6.
2, 4, 6.
4.) The nurse working in the intensive care unit (ICU) is assessing a
client who sustained a basilar skull fracture 24 hours ago. It is most
important to follow up with the primary health care provider (PHCP) if
the client
becomes irritable and
restless. has bruises under
the eyes.
is unable to name the state capital.
, 2
reports having a persistent headache since admission.
, 3
5.) The nurse is assessing a client who has experienced a mild
traumatic brain injury (TBI). Which findings from the box below are
consistent with this diagnosis?
1 Dizziness and gait problems.
2 A widened pulse pressure.
3 Increased sensitivity to light or noise.
4 A Glasgow Coma Scale (GCS) score of 9.
5 Dilated pupils that are nopreactive to light.
6 Amnesia about the events around the time of injury.
1, 3, 6.
3, 5, 6.
2, 3, 4, 5.
1, 2, 4, 6.
6.) The nurse is providing discharge instructions to the parents of
a 15-year-old female who sustained a concussion while plaving
field back
Which of the following statements by a parent indicates a need for
further teaching?
"We should avoid giving any acetaminophen to treat headaches.
"We need to bring our daughter back te the emergency department if she exhibits
blurred vision."
"We should provide a consistent routine at home to assist with any behavior
changes." "We will not allow our daughter to engage in strenuous activity for
at least 48 hours."
7.) The nurse is assessing clients for the risk of sustaining a
traumatic brain injury (TBI). Which of the following clients should
the nurse identify as being at greatest risk?
45-year-old who has epilepsy and takes phenytoin.
75-year-old who lives alone and has macular degeneration.
7-year-old who is learning how to ride a bicycle without training
wheels. 20-year-old college student who participates on the
tennis team.
8.) The nurse is providing discharge instructions to the partner of
a client who sustained a mild head injury as a result of a motor
vehicle crash. Which of the following statements by a partner
indicates a need for farther teaching?
"It is expected that my partner will have drainage from the nose for the next
few days." "I will provide my partner with aeetaminophen every 4 hours for
