Nursing NUR401 Test 2 – Chapter TB Practice Questions and Answers Study
Guide
Family members ask the nurse about the purpose of the ventriculostomy system being used for
intracranial pressure monitoring for a client. Which of the following responses by the nurse is
best?
"This type of monitoring system is complex and highly skilled staff are needed."
"The monitoring system helps show whether blood flow to the brain is adequate."
"The ventriculostomy monitoring system helps check for alterations in cerebralperfusion
pressure."
"This monitoring system has multiple benefits including facilitation ofcerebro-spinal fluid
drainage." - ✔✔"The monitoring system helps show whether blood flow to the brain is
adequate."
The nurse is caring for a client with a head injury and has admission vital signs of bloodpressure
128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs
if taken 1 hr after admission will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30 - ✔✔a. Blood pressure 156/60, pulse 55,
respirations 12
, The nurse is assessing a client who is unconscious and applies a painful stimulus to the nail
beds. The client responds with internal rotation, adduction, and flexion of the arms. Which of
the following terms should the nurse use when documenting the findings?
Flexion withdrawal
Localization of pain
Decorticate posturing
Decerebrate posturing - ✔✔Decorticate posturing
Which of the following parameters is best for the nurse to monitor to determine whether the
prescribed IV mannitol has been effective for an unconscious client?
Hematocrit
Blood pressure
Oxygen saturation
Intracranial pressure - ✔✔Intracranial pressure
A client with a head injury opens his or her eyes to verbal stimulation, curses when stimulated,
and does not respond to a verbal command to move but attempts to remove a painful stimulus.
Which of the following Glasgow Coma Scale scores should the nurse document?
a. 9
b. 11
c. 13
d. 15 - ✔✔b.11
The nurse is admitting a client to the emergency department (ED) who is unconscious following
a head injury. The client's spouse and children stay at the client's side and constantly ask about
the treatment being given. What of the following actions is best for the nurse to take?
Guide
Family members ask the nurse about the purpose of the ventriculostomy system being used for
intracranial pressure monitoring for a client. Which of the following responses by the nurse is
best?
"This type of monitoring system is complex and highly skilled staff are needed."
"The monitoring system helps show whether blood flow to the brain is adequate."
"The ventriculostomy monitoring system helps check for alterations in cerebralperfusion
pressure."
"This monitoring system has multiple benefits including facilitation ofcerebro-spinal fluid
drainage." - ✔✔"The monitoring system helps show whether blood flow to the brain is
adequate."
The nurse is caring for a client with a head injury and has admission vital signs of bloodpressure
128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs
if taken 1 hr after admission will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30 - ✔✔a. Blood pressure 156/60, pulse 55,
respirations 12
, The nurse is assessing a client who is unconscious and applies a painful stimulus to the nail
beds. The client responds with internal rotation, adduction, and flexion of the arms. Which of
the following terms should the nurse use when documenting the findings?
Flexion withdrawal
Localization of pain
Decorticate posturing
Decerebrate posturing - ✔✔Decorticate posturing
Which of the following parameters is best for the nurse to monitor to determine whether the
prescribed IV mannitol has been effective for an unconscious client?
Hematocrit
Blood pressure
Oxygen saturation
Intracranial pressure - ✔✔Intracranial pressure
A client with a head injury opens his or her eyes to verbal stimulation, curses when stimulated,
and does not respond to a verbal command to move but attempts to remove a painful stimulus.
Which of the following Glasgow Coma Scale scores should the nurse document?
a. 9
b. 11
c. 13
d. 15 - ✔✔b.11
The nurse is admitting a client to the emergency department (ED) who is unconscious following
a head injury. The client's spouse and children stay at the client's side and constantly ask about
the treatment being given. What of the following actions is best for the nurse to take?
