NR 464 - Exam 3 (PowerPoint
Questions) With complete verified
solutions (Guaranteed Pass)
Successful achievement of patient outcomes for the patient with cranial
surgery would best be indicated by the
a) Ability to meet all self-care needs.
b) Acceptance of residual neurologic deficits.
c) Absence of signs and symptoms of increased ICP.
d) Initiation of oral intake 72 hours after surgery. - answer c) Absence of
signs and symptoms of increased ICP.
When a patient is admitted to the emergency department following a
head injury, the nurse's first priority in management of the patient once
a patent airway is confirmed is:
a) Maintaining cervical spine precautions.
b) Determining the presence of increased ICP.
c) Monitoring for changes in neurologic exam.
, d) Establishing IV access with a large-bore catheter. - answer a)
Maintaining cervical spine precautions.
A patient with a head injury has clear drainage from the ear. To
determine whether CSF is present in the drainage the nurse (Select on
that apply):
a) Examines the tympanic membrane for a tear.
b) Tests the fluid with for a halo sign on a white dressing
c) Sends the drainage to the lab to check protein content.
d) Tests the fluid with a glucose-identifying strip or stick - answer b)
Tests the fluid with for a halo sign on a white dressing
d) Tests the fluid with a glucose-identifying strip or stick
The nurse recognizes the presence of Cushing's triad in the patient with:
a) Increased pulse, irregular respirations, increased BP
b) Decreased pulse, irregular respirations, increased pulse pressure
c) Increased pulse, decreased respiration, increased pulse pressure
d) Decreased pulse, increased respirations, decreased systolic BP -
answer b) Decreased pulse, irregular respirations, increased pulse
pressure
Questions) With complete verified
solutions (Guaranteed Pass)
Successful achievement of patient outcomes for the patient with cranial
surgery would best be indicated by the
a) Ability to meet all self-care needs.
b) Acceptance of residual neurologic deficits.
c) Absence of signs and symptoms of increased ICP.
d) Initiation of oral intake 72 hours after surgery. - answer c) Absence of
signs and symptoms of increased ICP.
When a patient is admitted to the emergency department following a
head injury, the nurse's first priority in management of the patient once
a patent airway is confirmed is:
a) Maintaining cervical spine precautions.
b) Determining the presence of increased ICP.
c) Monitoring for changes in neurologic exam.
, d) Establishing IV access with a large-bore catheter. - answer a)
Maintaining cervical spine precautions.
A patient with a head injury has clear drainage from the ear. To
determine whether CSF is present in the drainage the nurse (Select on
that apply):
a) Examines the tympanic membrane for a tear.
b) Tests the fluid with for a halo sign on a white dressing
c) Sends the drainage to the lab to check protein content.
d) Tests the fluid with a glucose-identifying strip or stick - answer b)
Tests the fluid with for a halo sign on a white dressing
d) Tests the fluid with a glucose-identifying strip or stick
The nurse recognizes the presence of Cushing's triad in the patient with:
a) Increased pulse, irregular respirations, increased BP
b) Decreased pulse, irregular respirations, increased pulse pressure
c) Increased pulse, decreased respiration, increased pulse pressure
d) Decreased pulse, increased respirations, decreased systolic BP -
answer b) Decreased pulse, irregular respirations, increased pulse
pressure
