NUR417 / NUR 417
FINAL EXAM
Care of Adult II, Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Expert Verified Explanation
➢ Multiple choice (single best answer)
➢ Select All That Apply (SATA)
➢ Fill-in-the-blank
➢ Case Studies/Scenario-Based Questions
,The nurse is providing care for a patient who has been admitted to the
hospital with a head injury and who requires regular neurologic and
vital sign assessment. Which assessments will be components of the
patient's score on the Glasgow Coma Scale (GCS) (select all that
apply)?
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
ANSWERS
B,D,E
The three dimensions of the GCS are eye opening, best verbal response,
and best motor response. Judgment, abstract reasoning, and cranial nerve
function are not components of the GCS.
A patient with a head injury opens the eyes to verbal stimulation,
curses when stimulated, and does not respond to a verbal command
to move but attempts to remove a painful stimulus. The nurse records
the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANSWER
B
,The patient has a score of 3 for eye opening, 3 for best verbal response,
and 5 for best motor response.
DIF: Cognitive Level: Application REF: 1434
A patient with a head injury has admission vital signs of blood
pressure 128/68, pulse 110, and respirations 26. Which of these vital
signs, if taken 1 hour after admission, will be of most concern to the
nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANSWER
A
Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad and indicate that the
intracranial pressure (ICP) has increased, and brain herniation may be
imminent unless immediate action is taken to reduce ICP. The other vital
signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
DIF: Cognitive Level: Application REF: 1429-1430
An unconscious patient has a nursing diagnosis of ineffective
cerebral tissue perfusion related to cerebral tissue swelling. Which
nursing intervention will be included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
, ANSWER
A
The patient with increased intracranial pressure (ICP) should be maintained
in the head-up position to help reduce ICP. Flexion of the hips and knees
increases abdominal pressure, which increases ICP. Because the
stimulation associated with nursing interventions increases ICP, clustering
interventions will progressively elevate ICP. Coughing increases
intrathoracic pressure and ICP.
DIF: Cognitive Level: Application REF: 1436-1437
A patient who is suspected of having an epidural hematoma is
admitted to the emergency department. Which action will the nurse
plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANSWER
D
The principal treatment for epidural hematoma is rapid surgery to remove
the hematoma and prevent herniation. If intracranial pressure (ICP) is
elevated after surgery, furosemide or high-dose barbiturate therapy may be
needed, but these will not be of benefit unless the hematoma is removed.
Minimal blood loss occurs with head injuries, and transfusion is usually not
necessary.
A patient has a systemic BP of 108/51 mm Hg and an intracranial
pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
FINAL EXAM
Care of Adult II, Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Expert Verified Explanation
➢ Multiple choice (single best answer)
➢ Select All That Apply (SATA)
➢ Fill-in-the-blank
➢ Case Studies/Scenario-Based Questions
,The nurse is providing care for a patient who has been admitted to the
hospital with a head injury and who requires regular neurologic and
vital sign assessment. Which assessments will be components of the
patient's score on the Glasgow Coma Scale (GCS) (select all that
apply)?
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
ANSWERS
B,D,E
The three dimensions of the GCS are eye opening, best verbal response,
and best motor response. Judgment, abstract reasoning, and cranial nerve
function are not components of the GCS.
A patient with a head injury opens the eyes to verbal stimulation,
curses when stimulated, and does not respond to a verbal command
to move but attempts to remove a painful stimulus. The nurse records
the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANSWER
B
,The patient has a score of 3 for eye opening, 3 for best verbal response,
and 5 for best motor response.
DIF: Cognitive Level: Application REF: 1434
A patient with a head injury has admission vital signs of blood
pressure 128/68, pulse 110, and respirations 26. Which of these vital
signs, if taken 1 hour after admission, will be of most concern to the
nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANSWER
A
Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad and indicate that the
intracranial pressure (ICP) has increased, and brain herniation may be
imminent unless immediate action is taken to reduce ICP. The other vital
signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
DIF: Cognitive Level: Application REF: 1429-1430
An unconscious patient has a nursing diagnosis of ineffective
cerebral tissue perfusion related to cerebral tissue swelling. Which
nursing intervention will be included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
, ANSWER
A
The patient with increased intracranial pressure (ICP) should be maintained
in the head-up position to help reduce ICP. Flexion of the hips and knees
increases abdominal pressure, which increases ICP. Because the
stimulation associated with nursing interventions increases ICP, clustering
interventions will progressively elevate ICP. Coughing increases
intrathoracic pressure and ICP.
DIF: Cognitive Level: Application REF: 1436-1437
A patient who is suspected of having an epidural hematoma is
admitted to the emergency department. Which action will the nurse
plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANSWER
D
The principal treatment for epidural hematoma is rapid surgery to remove
the hematoma and prevent herniation. If intracranial pressure (ICP) is
elevated after surgery, furosemide or high-dose barbiturate therapy may be
needed, but these will not be of benefit unless the hematoma is removed.
Minimal blood loss occurs with head injuries, and transfusion is usually not
necessary.
A patient has a systemic BP of 108/51 mm Hg and an intracranial
pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
