MED SURG 3 EXAM 3.
1. A nurse should anticipate giving a client with a tempoparol parietal fracture which of
the following meds to reduce ICP? Mannitol
2. If a clients paCO2 level rises, what happens to the cerebral blood flow? Dilates
3. An expected outcome of mannitol or furosemide administration in clients with increased ICP
is? Increase urine output
4. A client diagnosed with DI has an order to receive vasopressin intranasally. Which of the
following assessments indicates to a nurse that the treat is effective? Urinating 3-4
hours
5. A client with a serum sodium of 115 has a decreased LOC and is complaining of a headache.
A nurse knows that the client is at risk for cerebral edema caused by? Shif t of fluid into
intracellular space
6. A client is admitted to the nuerological ICU following a MVA which resulted in a closed
head injury. Which of the following is an appropriate short term goal for this client? Icp
shouldn’t increase 15
7. A client is brought to ER immediately after a head trauma that resulted in a fracture to the
temporal bone. What clinical manifestation is considered a neurological emergency? Change
in LOC
8. The family of a client with a severe head injury states that they do not understand why the
client is being put into a drug induced (barbiturate) coma when brain damage may be present.
Whats the nurses best response? This med is used to decrease the activity of the brain so more
damage doesn’t occur
9. During assessment of a client with a head injury, a nurse notes that the arms, wrists, and
fingers are flexed, and the arms are adducted. The nurse notes? Decorticate
10. The nurse is caring for a client postop who had a craniotomy. The nurse is preparing meperidine
(Demerol) 100 mg when the client complains of pain of 7. The medication available on the unit
is meperidine 20mg/ml. at this time, the nurse should administer? 0.5 mL and another RN to
witness the waste
11. Four victims of an automobile accident are brought by ambulance to the ER. The nurse
determines that the victim who has the highest priority for treatment is? Sucking chest
wound
12. A client with a spinal cord injury at C3-4 is being cared for in the ER. What is the
priority assessment? Monitor resp effort and oxygen saturation level
13. The nurse on the rehab unit is caring for the following clients. Which client should the
nurse assess first after receiving the change of shift report? C6 spinal cord who is
complaining of dyspnea and has crackles in his lungs
14. Bowel and bladder function are impaired after a complete spinal cord injury. Which of the
following statements about what occurs immediately after the injury is true? NG tube
usually inserted to decompress the stomach
15. A nurse is caring for a client who has had a complete cervical spine injury for many years. The
client tells the nurse he has an extreme headache. The nurse assesses a blood pressure of
190/100. Which of the following interventions should be performed first? Look for kinked
foley catheter and bowel impaction
1. A nurse should anticipate giving a client with a tempoparol parietal fracture which of
the following meds to reduce ICP? Mannitol
2. If a clients paCO2 level rises, what happens to the cerebral blood flow? Dilates
3. An expected outcome of mannitol or furosemide administration in clients with increased ICP
is? Increase urine output
4. A client diagnosed with DI has an order to receive vasopressin intranasally. Which of the
following assessments indicates to a nurse that the treat is effective? Urinating 3-4
hours
5. A client with a serum sodium of 115 has a decreased LOC and is complaining of a headache.
A nurse knows that the client is at risk for cerebral edema caused by? Shif t of fluid into
intracellular space
6. A client is admitted to the nuerological ICU following a MVA which resulted in a closed
head injury. Which of the following is an appropriate short term goal for this client? Icp
shouldn’t increase 15
7. A client is brought to ER immediately after a head trauma that resulted in a fracture to the
temporal bone. What clinical manifestation is considered a neurological emergency? Change
in LOC
8. The family of a client with a severe head injury states that they do not understand why the
client is being put into a drug induced (barbiturate) coma when brain damage may be present.
Whats the nurses best response? This med is used to decrease the activity of the brain so more
damage doesn’t occur
9. During assessment of a client with a head injury, a nurse notes that the arms, wrists, and
fingers are flexed, and the arms are adducted. The nurse notes? Decorticate
10. The nurse is caring for a client postop who had a craniotomy. The nurse is preparing meperidine
(Demerol) 100 mg when the client complains of pain of 7. The medication available on the unit
is meperidine 20mg/ml. at this time, the nurse should administer? 0.5 mL and another RN to
witness the waste
11. Four victims of an automobile accident are brought by ambulance to the ER. The nurse
determines that the victim who has the highest priority for treatment is? Sucking chest
wound
12. A client with a spinal cord injury at C3-4 is being cared for in the ER. What is the
priority assessment? Monitor resp effort and oxygen saturation level
13. The nurse on the rehab unit is caring for the following clients. Which client should the
nurse assess first after receiving the change of shift report? C6 spinal cord who is
complaining of dyspnea and has crackles in his lungs
14. Bowel and bladder function are impaired after a complete spinal cord injury. Which of the
following statements about what occurs immediately after the injury is true? NG tube
usually inserted to decompress the stomach
15. A nurse is caring for a client who has had a complete cervical spine injury for many years. The
client tells the nurse he has an extreme headache. The nurse assesses a blood pressure of
190/100. Which of the following interventions should be performed first? Look for kinked
foley catheter and bowel impaction
