PNH 301 Test 1 Practice Question And
Answers
/. Client has meningitis, what should the nurse find during assessment? - Answer-
Flexion of the hip and knees with passive flexion of the neck.
/.Priority actin for taking care of patient with seizure - Answer-Protecting patient from
injury.
/.What do you do prior to a electorconvusive therapy? - Answer-Spinal X-ray
/.Priority action for a tonic-clonic seizure - Answer-Note the first thing the client does;
this provides information on which part in the brain the seizure began.
/.Priority nursing intervention for closed head injury - Answer-maintain adequate airway
/.Most important risk factor for a stroke - Answer-Hypertension
/.Unstable spinal cord at T7. What is priority action during care? - Answer-Place client
on pressure reducing support surface; they are at risk for skin breakdown due to
immobility
/.Most helpful intervention with AD. - Answer-Communication strategies
/.A client with spinal cord injury is at risk for experiencing autonomic dysreflexia. The
nurse will monitor this manifestations - Answer-Sever throbbing headache
/.How should a nurse care for a client with receptive and expressive aphasia,
communicate with them? - Answer-Use hands to communicate, use picture board and
flash cards, and speak slowly.
/.Nurse is caring for Epidermal Hematoma. What are the nursing interventions? -
Answer--Ensure pulse oximeter is greater than 93%
- Administer mild sedatives
- Administer stool softeners daily
/.Client is unconscious following a tonic-clonic seizure, what should the nurse do first? -
Answer-Place client on side-lying position
/.What findings should indicate that traumatic brain injury has resulted in brain death? -
Answer-- No spontaneous respirations
- No response to cold test
Answers
/. Client has meningitis, what should the nurse find during assessment? - Answer-
Flexion of the hip and knees with passive flexion of the neck.
/.Priority actin for taking care of patient with seizure - Answer-Protecting patient from
injury.
/.What do you do prior to a electorconvusive therapy? - Answer-Spinal X-ray
/.Priority action for a tonic-clonic seizure - Answer-Note the first thing the client does;
this provides information on which part in the brain the seizure began.
/.Priority nursing intervention for closed head injury - Answer-maintain adequate airway
/.Most important risk factor for a stroke - Answer-Hypertension
/.Unstable spinal cord at T7. What is priority action during care? - Answer-Place client
on pressure reducing support surface; they are at risk for skin breakdown due to
immobility
/.Most helpful intervention with AD. - Answer-Communication strategies
/.A client with spinal cord injury is at risk for experiencing autonomic dysreflexia. The
nurse will monitor this manifestations - Answer-Sever throbbing headache
/.How should a nurse care for a client with receptive and expressive aphasia,
communicate with them? - Answer-Use hands to communicate, use picture board and
flash cards, and speak slowly.
/.Nurse is caring for Epidermal Hematoma. What are the nursing interventions? -
Answer--Ensure pulse oximeter is greater than 93%
- Administer mild sedatives
- Administer stool softeners daily
/.Client is unconscious following a tonic-clonic seizure, what should the nurse do first? -
Answer-Place client on side-lying position
/.What findings should indicate that traumatic brain injury has resulted in brain death? -
Answer-- No spontaneous respirations
- No response to cold test
