Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
1. The nurse is working in the emergency department and is admitting a client
who has a sustained TBI, following a motor vehicle crash, it is a priority for the
nurse to notify the primary health care provider if the client: takes prescribed warfarin
daily
2. The charge nurse observes a newly hired nurse caring for a client who sus-
tained a closed head
injury, is receiving mechanical ventilation, and is at risk for developing ICP.
Which of the following
actions, if performed by the newly hired nurse, requires intervention by the
charge nurse?: raising the foot of the clients bed
3. The newly hired nurse is caring for a client who was admitted 12 hours ago
with a TBI and is at risk
for developing ICP. It requires intervention by the nurse preceptor if the newly
hired nurse is observed: Clustering client care activities
4. The nurse is assessing clients for the risk of sustaining TBI. Which of the
following clients should
the nurse identify as being at greatest risk?: 20 yr old college student who participates on the
football team
5. The nurse is caring for assigned clients. Which of the following assessment
findings requires the
nurse to notify the PHCP?: the development of asymmetric pupils with no reaction to light in the client
who has the TBI
6. The nurse is caring for a client with a TBI and a skull fracture. The nurse noted
that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following
actions should the
nurse take next?: Perform a halo sign test
7. The nurse is providing discharge instructions to a client's partner who sus-
tained a mild head
injury due to an MVA. Which of the following statements, if made by the
partners, would indicate
the need for additional teaching?: i will bring my partner to the ED if they immediately starting vomiting
1/6
, Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
8. The nurse is caring for the following assigned clients. Which client should the
nurse see first?: The client who has brain injusry and bp change from 110/58 to 134/40
9. The nurse is caring for a client who is 24 hours post-op following a craniotomy.
The client is
reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which
of the following actions should the nurse take?: Perform a neurological test
10. The nurse is caring for a client who has encephalitis. It is priority for the nurse
to follow up if the
client: has a change in BP from 120/78 to 130/60
11. The nurse is caring for a client who has been admitted with suspected
bacterial meningitis. Which
of the following actions should the nurse take first?: Prepare the client for a lumbar puncture
12. The nurse is caring for the client who has confusion, fever, headache, blurred
vision, NV, and a
history of HIV. Which of the following actions should the nurse take first?: imple-
ment seizure precautions
13. Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports
blurred vision, BP 145/95,
HR 68, O2 95%. Which of the following actions should the nurse take?: palpate the
clients bladder (Autonomic dysreflexia)
14. The nurse working in the ED is caring for a client admitted with a suspected
spinal cord injury. It
would require follow up by the nurse if the PHCP prescribed which of the
following?: Mannitol
15. The nurse has taught a client who has myasthenia gravis about taking their
prescribed
medications on time and 45-60 mins prior to meals. The client asks why timing
is so important. Which
of the following is an appropriate response by the nurse?: this allows the medication to
have maximum effect, so its easier to swallow
16. The nurse is working in the ED is caring for a client who has MG. The client
presents with muscle
2/6
Study online at https://quizlet.com/_d8r6jq
1. The nurse is working in the emergency department and is admitting a client
who has a sustained TBI, following a motor vehicle crash, it is a priority for the
nurse to notify the primary health care provider if the client: takes prescribed warfarin
daily
2. The charge nurse observes a newly hired nurse caring for a client who sus-
tained a closed head
injury, is receiving mechanical ventilation, and is at risk for developing ICP.
Which of the following
actions, if performed by the newly hired nurse, requires intervention by the
charge nurse?: raising the foot of the clients bed
3. The newly hired nurse is caring for a client who was admitted 12 hours ago
with a TBI and is at risk
for developing ICP. It requires intervention by the nurse preceptor if the newly
hired nurse is observed: Clustering client care activities
4. The nurse is assessing clients for the risk of sustaining TBI. Which of the
following clients should
the nurse identify as being at greatest risk?: 20 yr old college student who participates on the
football team
5. The nurse is caring for assigned clients. Which of the following assessment
findings requires the
nurse to notify the PHCP?: the development of asymmetric pupils with no reaction to light in the client
who has the TBI
6. The nurse is caring for a client with a TBI and a skull fracture. The nurse noted
that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following
actions should the
nurse take next?: Perform a halo sign test
7. The nurse is providing discharge instructions to a client's partner who sus-
tained a mild head
injury due to an MVA. Which of the following statements, if made by the
partners, would indicate
the need for additional teaching?: i will bring my partner to the ED if they immediately starting vomiting
1/6
, Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
8. The nurse is caring for the following assigned clients. Which client should the
nurse see first?: The client who has brain injusry and bp change from 110/58 to 134/40
9. The nurse is caring for a client who is 24 hours post-op following a craniotomy.
The client is
reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which
of the following actions should the nurse take?: Perform a neurological test
10. The nurse is caring for a client who has encephalitis. It is priority for the nurse
to follow up if the
client: has a change in BP from 120/78 to 130/60
11. The nurse is caring for a client who has been admitted with suspected
bacterial meningitis. Which
of the following actions should the nurse take first?: Prepare the client for a lumbar puncture
12. The nurse is caring for the client who has confusion, fever, headache, blurred
vision, NV, and a
history of HIV. Which of the following actions should the nurse take first?: imple-
ment seizure precautions
13. Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports
blurred vision, BP 145/95,
HR 68, O2 95%. Which of the following actions should the nurse take?: palpate the
clients bladder (Autonomic dysreflexia)
14. The nurse working in the ED is caring for a client admitted with a suspected
spinal cord injury. It
would require follow up by the nurse if the PHCP prescribed which of the
following?: Mannitol
15. The nurse has taught a client who has myasthenia gravis about taking their
prescribed
medications on time and 45-60 mins prior to meals. The client asks why timing
is so important. Which
of the following is an appropriate response by the nurse?: this allows the medication to
have maximum effect, so its easier to swallow
16. The nurse is working in the ED is caring for a client who has MG. The client
presents with muscle
2/6
