MS3 Exam 1 Questions With Correct
Answers
A 45 year old patient has just been admitted into the ER after a MVC. What is the
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nurses priority intervention?
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A. complete a glasgow coma scale assessment
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B. ask the patient if they have insurance
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C. obtain and EKG on the patient
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D. Check that the patient has an airway - CORRECT ANSWER✔✔-D
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ABCs, airway is priority. pts with a head injury are at risk for hypoxia and
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respiratory failure. |
What are interventions for preventing increased ICP in a TBI patient? SATA
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A. maintain ICP > 20
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B. raise the HOB (head of bed) >30 degrees
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C. start ordered IV mannitol
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D. suction the patient q5 minutes
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E. give patient prescribed miralax - CORRECT ANSWER✔✔-B,C,E
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ICP should be between 10-15mmHg. suctioning raises ICP and should be done
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only in emergencies.
| | |
,mannitol is a diuretic that decreases ICP. miralax is a stool softener that helps
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prevent bowel strain that can increase ICP.
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Which TBI patient needs immediate intervention from the nurse?
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A. A patient who was speaking a few minutes ago but now is not speaking and
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has a unreactive R pupil
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B. A patient who is sleeping with HOB <30
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C. A patient who is screaming at the nurses to get him something for his pain that
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is 10/10
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D. A patient who needs to have a bowel movement and is asking for a bedpan -
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CORRECT ANSWER✔✔-A |
this patient is the most critical. A change in LOC, change in pupil reaction,
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breathing pattern changes, hemodynamic instability, and drooping eyelids are all
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sings of danger in a TBI patient. The RRT team should be called immediately.
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Which of the following are signs of Cushing's triad? SATA
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A. BP 220/82
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B. HR 55| |
C. widened pulse pressure
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D. HR 110 - CORRECT ANSWER✔✔-A,B,C
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cushing's triad: hypertension, bradycardia, and a widened pulse pressure
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A client has a traumatic brain injury. The nurse assesses the following: pulse
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change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg,
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and respiratory irregularities. What action by the nurse takes priority?
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a. Call the provider or Rapid Response Team.
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,b. Increase the rate of the IV fluid administration.
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c. Notify respiratory therapy for a breathing treatment.
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d. Prepare to give IV pain medication. - CORRECT ANSWER✔✔-A
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These manifestations indicate Cushing's syndrome, a potentially life-threatening
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increase in intracranial pressure (ICP), which is an emergency. Immediate medical
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attention is necessary, so the nurse notifies the provider or the Rapid Response
| | | | | | | | | | | | |
Team. Increasing fluids would increase the ICP. The client does not need a
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breathing treatment or pain medication. | | | |
A nurse is caring for four clients in the neurologic intensive care unit. After
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receiving the hand-off report, which client should the nurse see first?
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a. Client with a Glasgow Coma Scale score that was 10 and is now is 8
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b. Client with a Glasgow Coma Scale score that was 9 and is now is 12
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c. Client with a moderate brain injury who is amnesic for the event
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d. Client who is requesting pain medication for a headache - CORRECT
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ANSWER✔✔-A
A 2-point decrease in the Glasgow Coma Scale score is clinically significant and
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the nurse needs to see this client first. An improvement in the score is a good
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sign. Amnesia is an expected finding with brain injuries, so this client is lower
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priority. The client requesting pain medication should be seen after the one with
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the declining Glasgow Coma Scale score
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A client is in the clinic for a follow-up visit after a moderate traumatic brain injury.
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The client's spouse is very frustrated, stating that the client's personality has
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changed and the situation is intolerable. What action by the nurse is best?
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, a. Explain that personality changes are common following brain injuries.
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b. Ask the client why he or she is acting out and behaving differently.
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c. Refer the client and spouse to a head injury support group.
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d. Tell the spouse this is expected and he or she will have to learn to cope. -
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CORRECT ANSWER✔✔-A |
Personality and behavior often change permanently after head injury. The nurse
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should explain this to the spouse. Asking the client about his or her behavior isn't
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useful because the client probably cannot help it. A referral might be a good idea,
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but the nurse needs to do something in addition to just referring the couple.
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Telling the spouse to learn to cope belittles the spouse's concerns and feelings.
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A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse
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questions the use of the drug, saying the client does not have a seizure disorder.
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What response by the nurse is best?
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a. "Increased pressure from the abscess can cause seizures."
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b. "Preventing febrile seizures with an abscess is important."
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c. "Seizures always occur in clients with brain abscesses."
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d. "This drug is used to sedate the client with an abscess." - CORRECT
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ANSWER✔✔-A
phenytoin is given in this circumstance to prevent seizures that can be caused by
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the abcess |
A client has a traumatic brain injury and a positive halo sign. The client is in the
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intensive care unit, sedated and on a ventilator, and is in critical but stable
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condition. What collaborative problem takes priority at this time?
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Answers
A 45 year old patient has just been admitted into the ER after a MVC. What is the
| | | | | | | | | | | | | | | | | |
nurses priority intervention?
| |
A. complete a glasgow coma scale assessment
| | | | | |
B. ask the patient if they have insurance
| | | | | | |
C. obtain and EKG on the patient
| | | | | |
D. Check that the patient has an airway - CORRECT ANSWER✔✔-D
| | | | | | | | | |
ABCs, airway is priority. pts with a head injury are at risk for hypoxia and
| | | | | | | | | | | | | | |
respiratory failure. |
What are interventions for preventing increased ICP in a TBI patient? SATA
| | | | | | | | | | |
A. maintain ICP > 20
| | | |
B. raise the HOB (head of bed) >30 degrees
| | | | | | | |
C. start ordered IV mannitol
| | | |
D. suction the patient q5 minutes
| | | | |
E. give patient prescribed miralax - CORRECT ANSWER✔✔-B,C,E
| | | | | | |
ICP should be between 10-15mmHg. suctioning raises ICP and should be done
| | | | | | | | | | | |
only in emergencies.
| | |
,mannitol is a diuretic that decreases ICP. miralax is a stool softener that helps
| | | | | | | | | | | | | |
prevent bowel strain that can increase ICP.
| | | | | |
Which TBI patient needs immediate intervention from the nurse?
| | | | | | | |
A. A patient who was speaking a few minutes ago but now is not speaking and
| | | | | | | | | | | | | | | |
has a unreactive R pupil
| | | |
B. A patient who is sleeping with HOB <30
| | | | | | | |
C. A patient who is screaming at the nurses to get him something for his pain that
| | | | | | | | | | | | | | | |
is 10/10
| |
D. A patient who needs to have a bowel movement and is asking for a bedpan -
| | | | | | | | | | | | | | | | |
CORRECT ANSWER✔✔-A |
this patient is the most critical. A change in LOC, change in pupil reaction,
| | | | | | | | | | | | | |
breathing pattern changes, hemodynamic instability, and drooping eyelids are all
| | | | | | | | | |
sings of danger in a TBI patient. The RRT team should be called immediately.
| | | | | | | | | | | | |
Which of the following are signs of Cushing's triad? SATA
| | | | | | | | |
A. BP 220/82
| |
B. HR 55| |
C. widened pulse pressure
| | |
D. HR 110 - CORRECT ANSWER✔✔-A,B,C
| | | | | |
cushing's triad: hypertension, bradycardia, and a widened pulse pressure
| | | | | | | |
A client has a traumatic brain injury. The nurse assesses the following: pulse
| | | | | | | | | | | | |
change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg,
| | | | | | | | | | | | | | |
and respiratory irregularities. What action by the nurse takes priority?
| | | | | | | | |
a. Call the provider or Rapid Response Team.
| | | | | | |
,b. Increase the rate of the IV fluid administration.
| | | | | | | |
c. Notify respiratory therapy for a breathing treatment.
| | | | | | |
d. Prepare to give IV pain medication. - CORRECT ANSWER✔✔-A
| | | | | | | | |
These manifestations indicate Cushing's syndrome, a potentially life-threatening
| | | | | | | |
increase in intracranial pressure (ICP), which is an emergency. Immediate medical
| | | | | | | | | | |
attention is necessary, so the nurse notifies the provider or the Rapid Response
| | | | | | | | | | | | |
Team. Increasing fluids would increase the ICP. The client does not need a
| | | | | | | | | | | | |
breathing treatment or pain medication. | | | |
A nurse is caring for four clients in the neurologic intensive care unit. After
| | | | | | | | | | | | | |
receiving the hand-off report, which client should the nurse see first?
| | | | | | | | | |
a. Client with a Glasgow Coma Scale score that was 10 and is now is 8
| | | | | | | | | | | | | | |
b. Client with a Glasgow Coma Scale score that was 9 and is now is 12
| | | | | | | | | | | | | | |
c. Client with a moderate brain injury who is amnesic for the event
| | | | | | | | | | | |
d. Client who is requesting pain medication for a headache - CORRECT
| | | | | | | | | | | |
ANSWER✔✔-A
A 2-point decrease in the Glasgow Coma Scale score is clinically significant and
| | | | | | | | | | | | |
the nurse needs to see this client first. An improvement in the score is a good
| | | | | | | | | | | | | | | |
sign. Amnesia is an expected finding with brain injuries, so this client is lower
| | | | | | | | | | | | | |
priority. The client requesting pain medication should be seen after the one with
| | | | | | | | | | | | |
the declining Glasgow Coma Scale score
| | | | |
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury.
| | | | | | | | | | | | | | |
The client's spouse is very frustrated, stating that the client's personality has
| | | | | | | | | | | | |
changed and the situation is intolerable. What action by the nurse is best?
| | | | | | | | | | | |
, a. Explain that personality changes are common following brain injuries.
| | | | | | | | |
b. Ask the client why he or she is acting out and behaving differently.
| | | | | | | | | | | | |
c. Refer the client and spouse to a head injury support group.
| | | | | | | | | | |
d. Tell the spouse this is expected and he or she will have to learn to cope. -
| | | | | | | | | | | | | | | | | |
CORRECT ANSWER✔✔-A |
Personality and behavior often change permanently after head injury. The nurse
| | | | | | | | | | |
should explain this to the spouse. Asking the client about his or her behavior isn't
| | | | | | | | | | | | | | |
useful because the client probably cannot help it. A referral might be a good idea,
| | | | | | | | | | | | | |
but the nurse needs to do something in addition to just referring the couple.
| | | | | | | | | | | | | | |
Telling the spouse to learn to cope belittles the spouse's concerns and feelings.
| | | | | | | | | | | |
A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse
| | | | | | | | | | | | |
questions the use of the drug, saying the client does not have a seizure disorder.
| | | | | | | | | | | | | | |
What response by the nurse is best?
| | | | | |
a. "Increased pressure from the abscess can cause seizures."
| | | | | | | |
b. "Preventing febrile seizures with an abscess is important."
| | | | | | | |
c. "Seizures always occur in clients with brain abscesses."
| | | | | | | |
d. "This drug is used to sedate the client with an abscess." - CORRECT
| | | | | | | | | | | | | |
ANSWER✔✔-A
phenytoin is given in this circumstance to prevent seizures that can be caused by
| | | | | | | | | | | | | |
the abcess |
A client has a traumatic brain injury and a positive halo sign. The client is in the
| | | | | | | | | | | | | | | | |
intensive care unit, sedated and on a ventilator, and is in critical but stable
| | | | | | | | | | | | | |
condition. What collaborative problem takes priority at this time?
| | | | | | | |
