NUR 265 - Exam 3 : Practice Questions
Study online at https://quizlet.com/_dl4ucy
1. the RN is working in the ED and is admitting takes prescribed warfarin daily
a pt who has sustained a TBI following a - bleeding rsk from primary TBI (possible
motor vehicle crash. it is priority for the RN hematoma)
to notify the PHCP if the pt..?
2. the charge RN is observing a newly hired RN raising the foot of the pt bed
care for a pt who sustained a closed head - should raise the HEAD, not the foot
injury, is receiving mechanical ventilation
and is at risk for developing ICP. which of
the following actions, if preformed by the
newly hired RN, requires intervention by
the charge RN?
3. the newly hired RN is caring for a pt who clustering the pt care activities
was admitted 12 hours ago with a TBI and - NEVER cluster care for these pts, it can
is at risk for developing ICP. it requires in- increase ICP dramatically
tervention by the RN preceptor if the newly
hired RN is observed?
4. the Rn is assessing pts for the risk of 20 year old college student who partici-
sustaining TBI. which of the following pts pates on the football team
should the RN identify as being at greatest - sport injuries : colliding with stationary
risk? object
5. the RN is caring for assigned pts. which the development of asymmetric pupils with
of the following assessement findings re- no reaction to light in a pt who has a TBI
quires the RN to notify the PHCP? - Sx of ICP
6. the RN is caring for a pt who had a TBI with preform a halo sign test
skull fx. the RN noted that the pt has devel- - determine if the nasal drainage is CSF
oped rhinorrhea that is positive for glucose.
which of the following actions should the
RN take next?
1/7
, NUR 265 - Exam 3 : Practice Questions
Study online at https://quizlet.com/_dl4ucy
7. the RN is providing discharge instructions if my partner is sleeping, i will wake them
to the partner of a pt who sustained a mild up every 5-6 hours
head injury as a result of a motor vehicle - let them sleep
crash. which of the following statements, if
made by a partner, would indicate the need
for additional teaching?
8. the RN is caring for the following assigned the pt who has a brain injury and a BP
pts. which pt should the RN see 1st? change from 110/58 to 134/40 mmHg
- Cushing's Triad
9. the RN is caring for a pt who is 24 hr postop preform a neuro assessment
following a craniotomy. the pt is reporting a - Sx of rapid progessive hydrocephalus
headache that is rated a 8/10. which of the
following action should the RN take?
10. the RN is caring for a pt who has encephali- reports having developed a headache
tis. it is a priority for the RN to follow up if - Sx of increasing ICP
the pt?
11. the RN is caring for a pt who has been ad- prepare the pt for a lumbar puncture
mitted with suspected bacterial meningitis. - the MOST important test! test CSF by lum-
which of the following action should the RN bar puncture prior to giving ABT
take 1st?
12. the RN is caring for a pt who has confu- implement seizure precautions
sion, fever, headache, blurred vision, nau-
sea, vomiting and a history of HIV. which
of the following actions should the RN take
1st?
13.
2/7
Study online at https://quizlet.com/_dl4ucy
1. the RN is working in the ED and is admitting takes prescribed warfarin daily
a pt who has sustained a TBI following a - bleeding rsk from primary TBI (possible
motor vehicle crash. it is priority for the RN hematoma)
to notify the PHCP if the pt..?
2. the charge RN is observing a newly hired RN raising the foot of the pt bed
care for a pt who sustained a closed head - should raise the HEAD, not the foot
injury, is receiving mechanical ventilation
and is at risk for developing ICP. which of
the following actions, if preformed by the
newly hired RN, requires intervention by
the charge RN?
3. the newly hired RN is caring for a pt who clustering the pt care activities
was admitted 12 hours ago with a TBI and - NEVER cluster care for these pts, it can
is at risk for developing ICP. it requires in- increase ICP dramatically
tervention by the RN preceptor if the newly
hired RN is observed?
4. the Rn is assessing pts for the risk of 20 year old college student who partici-
sustaining TBI. which of the following pts pates on the football team
should the RN identify as being at greatest - sport injuries : colliding with stationary
risk? object
5. the RN is caring for assigned pts. which the development of asymmetric pupils with
of the following assessement findings re- no reaction to light in a pt who has a TBI
quires the RN to notify the PHCP? - Sx of ICP
6. the RN is caring for a pt who had a TBI with preform a halo sign test
skull fx. the RN noted that the pt has devel- - determine if the nasal drainage is CSF
oped rhinorrhea that is positive for glucose.
which of the following actions should the
RN take next?
1/7
, NUR 265 - Exam 3 : Practice Questions
Study online at https://quizlet.com/_dl4ucy
7. the RN is providing discharge instructions if my partner is sleeping, i will wake them
to the partner of a pt who sustained a mild up every 5-6 hours
head injury as a result of a motor vehicle - let them sleep
crash. which of the following statements, if
made by a partner, would indicate the need
for additional teaching?
8. the RN is caring for the following assigned the pt who has a brain injury and a BP
pts. which pt should the RN see 1st? change from 110/58 to 134/40 mmHg
- Cushing's Triad
9. the RN is caring for a pt who is 24 hr postop preform a neuro assessment
following a craniotomy. the pt is reporting a - Sx of rapid progessive hydrocephalus
headache that is rated a 8/10. which of the
following action should the RN take?
10. the RN is caring for a pt who has encephali- reports having developed a headache
tis. it is a priority for the RN to follow up if - Sx of increasing ICP
the pt?
11. the RN is caring for a pt who has been ad- prepare the pt for a lumbar puncture
mitted with suspected bacterial meningitis. - the MOST important test! test CSF by lum-
which of the following action should the RN bar puncture prior to giving ABT
take 1st?
12. the RN is caring for a pt who has confu- implement seizure precautions
sion, fever, headache, blurred vision, nau-
sea, vomiting and a history of HIV. which
of the following actions should the RN take
1st?
13.
2/7
