Medical-Surgical Nursing Exam 1 Jersey
College Questions with 100% Complete
Solutions, Graded to Pass
-removing all bedding over the patient (with the possible exception of a light
sheet, towel, or small drape)
-administering acetaminophen as prescribed
-giving cool sponge baths and allowing an electric fan to blow over the patient
to increase surface cooling
-using a hypothermia blanket
-frequent temperature monitoring to assess the patient's response to the therapy
and to prevent an excessive decrease in temperature and shivering - Correct
Solution Strategies for reducing fever/hyperthermia treatment
-change in LOC
-agitation
-slowing of speech
-and delay in response to verbal suggestions are other early indicators - Correct
Solution Early indicators of increasing ICP
4 spontaneous
3 to voice
2 to pain
1 none - Correct Solution GLASGOW COMA SCALE - Eye Opening
5 oriented
4 confused
3 inappropriate words
2 incomprehensible sounds
, 1 none - Correct Solution GLASGOW COMA SCALE -Best Verbal Response
6 obeys commands
5 localizes pain
4 withdraws
3 flexion
2 extension
1 none - Correct Solution GLASGOW COMA SCALE - Best Motor Response
Rectally or tympanic. NEVER BY MOUTH. - Correct Solution How should
the patient who is unconscious have their temperature taken?
-mouth care with antiseptic such as chlorhexidine
-tongue scraper
-electrical toothbrush
-pharmacologic moisturizers - Correct Solution List interventions to decrease
ventilator-associated pneumonia. (4)
-incontinence
-inadequate dietary intake
-pressure on bony prominences
-edema - Correct Solution Factors that contribute to impaired skin integrity (4)
increased ICP - Correct Solution slow bounding pulse and respiratory
irregularities suggest what?
cerebral vasodilation, leading to increased cerebral blood flow and increased
ICP - Correct Solution An increase in the partial pressure of arterial carbon
dioxide (PaCO2) causes ?
College Questions with 100% Complete
Solutions, Graded to Pass
-removing all bedding over the patient (with the possible exception of a light
sheet, towel, or small drape)
-administering acetaminophen as prescribed
-giving cool sponge baths and allowing an electric fan to blow over the patient
to increase surface cooling
-using a hypothermia blanket
-frequent temperature monitoring to assess the patient's response to the therapy
and to prevent an excessive decrease in temperature and shivering - Correct
Solution Strategies for reducing fever/hyperthermia treatment
-change in LOC
-agitation
-slowing of speech
-and delay in response to verbal suggestions are other early indicators - Correct
Solution Early indicators of increasing ICP
4 spontaneous
3 to voice
2 to pain
1 none - Correct Solution GLASGOW COMA SCALE - Eye Opening
5 oriented
4 confused
3 inappropriate words
2 incomprehensible sounds
, 1 none - Correct Solution GLASGOW COMA SCALE -Best Verbal Response
6 obeys commands
5 localizes pain
4 withdraws
3 flexion
2 extension
1 none - Correct Solution GLASGOW COMA SCALE - Best Motor Response
Rectally or tympanic. NEVER BY MOUTH. - Correct Solution How should
the patient who is unconscious have their temperature taken?
-mouth care with antiseptic such as chlorhexidine
-tongue scraper
-electrical toothbrush
-pharmacologic moisturizers - Correct Solution List interventions to decrease
ventilator-associated pneumonia. (4)
-incontinence
-inadequate dietary intake
-pressure on bony prominences
-edema - Correct Solution Factors that contribute to impaired skin integrity (4)
increased ICP - Correct Solution slow bounding pulse and respiratory
irregularities suggest what?
cerebral vasodilation, leading to increased cerebral blood flow and increased
ICP - Correct Solution An increase in the partial pressure of arterial carbon
dioxide (PaCO2) causes ?
