NUR390 / NUR 390 EXAM 3
Nursing Care of Adult I
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Actual Questions and Answers
➢ Multiple choice (single best answer)
➢ Case Studies/Scenario-Based Questions
,Family members of a patient who has a traumatic brain injury ask the
nurse about the purpose of the ventriculostomy system being used
for intracranial pressure monitoring. Which statement by the nurse
would be the best initial response for this situation?
a. "This is a complex type of monitoring system, and it is managed by
skilled staff."
b. "The system measures pressures to determine whether blood flow
to the brain is adequate"
c. "The ventriculostomy monitoring system helps check for changes
in cerebral perfusion pressure."
d. "This monitoring system has many benefits, including the ability to
drain cerebrospinal fluid."
Answer
b. "The system measures pressures to determine whether blood flow to the
brain is adequate"
Admission vital signs for a patient who has a brain injury are blood
pressure of 128/68 mm Hg, pulse of 10 beats/min, and of respirations
26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of
most concern to the nurse?
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
,b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32
breaths/min
c. Blood pressure 148/78 mm Hg, pulse 12 beats/min, respirations 28
breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30
breaths/min
Answer
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
When a brain-injured patient responds to nail bed pressure with
internal rotation, adduction, and flexion of the arms, how would the
nurse report the response?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
Answer
c. Decorticate posturing
The nurse has administered prescribed IV mannitol (Osmitrol) to an
unconscious patient. Which parameter would the nurse monitor to
determine the medication's effectiveness?
a. Blood pressure
b. Oxygen saturation
, c. Intracranial pressure
d. Hemoglobin and hematocrit
Answer
c. Intracranial pressure
A patient with a head injury opens his eyes to verbal stimulation,
curses when stimulated, and does not respond to a verbal command
to move but attempts to push away a painful stimulus. How would the
nurse record the patient's Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
Answer
b. 11
An unconscious patient is admitted to the emergency department
(ED) with a head injury. The patient's spouse and teenage children
stay at the patient's side and ask many questions about the treatment.
Which action is best for the nurse to take?
a. Call the family's pastor or spiritual advisor ot take them to the
chapel.
b. Ask the family to stay in the waiting room until the assessment is
completed.
c. Allow the family to stay with the patient and briefly explain all
Nursing Care of Adult I
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Actual Questions and Answers
➢ Multiple choice (single best answer)
➢ Case Studies/Scenario-Based Questions
,Family members of a patient who has a traumatic brain injury ask the
nurse about the purpose of the ventriculostomy system being used
for intracranial pressure monitoring. Which statement by the nurse
would be the best initial response for this situation?
a. "This is a complex type of monitoring system, and it is managed by
skilled staff."
b. "The system measures pressures to determine whether blood flow
to the brain is adequate"
c. "The ventriculostomy monitoring system helps check for changes
in cerebral perfusion pressure."
d. "This monitoring system has many benefits, including the ability to
drain cerebrospinal fluid."
Answer
b. "The system measures pressures to determine whether blood flow to the
brain is adequate"
Admission vital signs for a patient who has a brain injury are blood
pressure of 128/68 mm Hg, pulse of 10 beats/min, and of respirations
26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of
most concern to the nurse?
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
,b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32
breaths/min
c. Blood pressure 148/78 mm Hg, pulse 12 beats/min, respirations 28
breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30
breaths/min
Answer
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12
breaths/min
When a brain-injured patient responds to nail bed pressure with
internal rotation, adduction, and flexion of the arms, how would the
nurse report the response?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
Answer
c. Decorticate posturing
The nurse has administered prescribed IV mannitol (Osmitrol) to an
unconscious patient. Which parameter would the nurse monitor to
determine the medication's effectiveness?
a. Blood pressure
b. Oxygen saturation
, c. Intracranial pressure
d. Hemoglobin and hematocrit
Answer
c. Intracranial pressure
A patient with a head injury opens his eyes to verbal stimulation,
curses when stimulated, and does not respond to a verbal command
to move but attempts to push away a painful stimulus. How would the
nurse record the patient's Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
Answer
b. 11
An unconscious patient is admitted to the emergency department
(ED) with a head injury. The patient's spouse and teenage children
stay at the patient's side and ask many questions about the treatment.
Which action is best for the nurse to take?
a. Call the family's pastor or spiritual advisor ot take them to the
chapel.
b. Ask the family to stay in the waiting room until the assessment is
completed.
c. Allow the family to stay with the patient and briefly explain all
