NUR 265 EXAM 3 SOLUTIONS
QUESTIONS AND ANSWERS WITH
OMPLETE SOLUTIONS ALREADY
PASSED!!!
Question: An emergency department nurse is admitting a patient who sustained a
traumatic brain injury (TBI) during a motor vehicle collision. Which piece of data
obtained during the initial assessment demands the most urgent, priority
notification to the primary healthcare provider?
Answer: ✔✔ The patient takes prescribed warfarin daily.
(Rationale: Warfarin is a potent anticoagulant. In the setting of a traumatic head
injury, pre-injury anticoagulation dramatically elevates the risk of rapid,
catastrophic intracranial hemorrhage, requiring immediate diagnostic imaging
and potential reversal therapy.)
Question: A charge nurse is evaluating a newly licensed nurse who is managing a
mechanically ventilated patient with a severe closed head injury who is at high risk
for increased intracranial pressure (ICP). Which action by the new nurse requires
immediate intervention by the charge nurse?
Answer: ✔✔ Raising the foot of the client's bed.
(Rationale: Elevating the lower extremities or placing the patient in a
Trendelenburg position increases venous return to the heart, which directly
impedes venous drainage from the brain. This rapidly raises intracranial pressure.
The head of the bed should be maintained at 30 to 45 degrees with the neck in a
neutral alignment.)
Question: A nurse preceptor is monitoring a new graduate nurse providing care to
a patient admitted 12 hours ago following a traumatic brain injury. The patient is
currently being monitored for signs of rising intracranial pressure. Which practice
by the new nurse requires the preceptor to step in and correct them?
Answer: ✔✔ Clustering client care activities.
(Rationale: While clustering care is an excellent strategy for general medical-
surgical patients to promote rest, it is strictly contraindicated for patients at risk
, for increased ICP. Combining multiple stimulating tasks—such as bathing,
turning, and suctioning—all at once causes cumulative spikes in intracranial
pressure that the injured brain cannot tolerate.)
The nurse is assessing clients for the risk of sustaining TBI. Which of the
following clients should
the nurse identify as being at greatest risk?
20 yr old college student who participates on the football team
The nurse is caring for assigned clients. Which of the following assessment
findings requires the
nurse to notify the PHCP?
the development of asymmetric pupils with no reaction to light in the client who
has the TBI
The nurse is caring for a client with a TBI and a skull fracture. The nurse noted
that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following
actions should the
nurse take next?
Perform a halo sign test
The nurse is providing discharge instructions to a client's partner who sustained a
mild head
QUESTIONS AND ANSWERS WITH
OMPLETE SOLUTIONS ALREADY
PASSED!!!
Question: An emergency department nurse is admitting a patient who sustained a
traumatic brain injury (TBI) during a motor vehicle collision. Which piece of data
obtained during the initial assessment demands the most urgent, priority
notification to the primary healthcare provider?
Answer: ✔✔ The patient takes prescribed warfarin daily.
(Rationale: Warfarin is a potent anticoagulant. In the setting of a traumatic head
injury, pre-injury anticoagulation dramatically elevates the risk of rapid,
catastrophic intracranial hemorrhage, requiring immediate diagnostic imaging
and potential reversal therapy.)
Question: A charge nurse is evaluating a newly licensed nurse who is managing a
mechanically ventilated patient with a severe closed head injury who is at high risk
for increased intracranial pressure (ICP). Which action by the new nurse requires
immediate intervention by the charge nurse?
Answer: ✔✔ Raising the foot of the client's bed.
(Rationale: Elevating the lower extremities or placing the patient in a
Trendelenburg position increases venous return to the heart, which directly
impedes venous drainage from the brain. This rapidly raises intracranial pressure.
The head of the bed should be maintained at 30 to 45 degrees with the neck in a
neutral alignment.)
Question: A nurse preceptor is monitoring a new graduate nurse providing care to
a patient admitted 12 hours ago following a traumatic brain injury. The patient is
currently being monitored for signs of rising intracranial pressure. Which practice
by the new nurse requires the preceptor to step in and correct them?
Answer: ✔✔ Clustering client care activities.
(Rationale: While clustering care is an excellent strategy for general medical-
surgical patients to promote rest, it is strictly contraindicated for patients at risk
, for increased ICP. Combining multiple stimulating tasks—such as bathing,
turning, and suctioning—all at once causes cumulative spikes in intracranial
pressure that the injured brain cannot tolerate.)
The nurse is assessing clients for the risk of sustaining TBI. Which of the
following clients should
the nurse identify as being at greatest risk?
20 yr old college student who participates on the football team
The nurse is caring for assigned clients. Which of the following assessment
findings requires the
nurse to notify the PHCP?
the development of asymmetric pupils with no reaction to light in the client who
has the TBI
The nurse is caring for a client with a TBI and a skull fracture. The nurse noted
that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following
actions should the
nurse take next?
Perform a halo sign test
The nurse is providing discharge instructions to a client's partner who sustained a
mild head
