NUR 265 EXAM 3 QUESTIONS AND
ANSWERS WITH COMPLETE
SOLUTIONS 100% CORRECT RATED
A+
Question: What specific vital sign finding indicates a traumatic brain injury (TBI)
patient is deteriorating and requires immediate medical attention?
✔✔ Answer: A blood pressure reading showing a widening pulse pressure (for
example, 166/53 mmHg). This is a hallmark sign of rising intracranial pressure
(Cushing's triad) and demands rapid intervention to safeguard the airway,
breathing, and circulation (ABCs).
Question: When managing a patient with acute cranial or cervical spine trauma,
what secondary musculoskeletal injuries must healthcare providers actively work
to prevent, and how?
✔✔ Answer: Providers must prevent secondary spinal cord damage, specifically
stabilizing the thoracic and lumbar vertebral regions. This is achieved by ensuring
the patient's entire spine is kept perfectly straight and in a strict midline position.
Question: Why is the coordination of nursing interventions handled differently for
patients recovering from a severe traumatic brain injury?
✔✔ Answer: Grouping or clustering nursing tasks together (cluster care) must be
avoided for TBI patients. Spacing out interventions prevents dangerous spikes in
intracranial pressure by minimizing overall sensory stimulation.
Question: What is the required therapeutic positioning for a patient diagnosed with
a traumatic brain injury?
✔✔ Answer: The patient's head and neck must be maintained in a neutral, midline
alignment to promote proper venous drainage from the brain.
Question: What type of environmental modifications should a nurse implement in
the room of a patient recovering from a head injury?
✔✔ Answer: The patient requires a low-stimulus, calm, and quiet environment to
keep
, Do NOT encourage coughing or deep breathing hourly as part of the plan of care
for a TBI patient -ANSWER ✔✔(this causes increased risk for ICP)
What is included in the plan of care for a TBI patient? -ANSWER ✔✔-
hyperoxygenate
-quiet environment
-avoid cluster care
What is a normal finding in TBI patient? -ANSWER ✔✔-amnesia at time of injury
-GCS score of 14
-photophobia
-balance and gait problems are consistent in TBI patients
What requires further intervention for a TBI patient (what is wrong) -ANSWER
✔✔-Do NOT encourage deep breathing or coughing (increases ICP)
-Do NOT do hip ROM exercises (need to be straight and midline)
-A widened pulse pressure is NOT consistent with TBI (intervention needed or
priority patient)
-Pupil changes are not expected and are an issue (brainstem issue)
which pt finding in skull fracture requires immediate MD notification? -ANSWER
✔✔becomes irritable and restlessness
What Glasgow coma scale is consistent with a TBI patient? -ANSWER ✔✔14
ANSWERS WITH COMPLETE
SOLUTIONS 100% CORRECT RATED
A+
Question: What specific vital sign finding indicates a traumatic brain injury (TBI)
patient is deteriorating and requires immediate medical attention?
✔✔ Answer: A blood pressure reading showing a widening pulse pressure (for
example, 166/53 mmHg). This is a hallmark sign of rising intracranial pressure
(Cushing's triad) and demands rapid intervention to safeguard the airway,
breathing, and circulation (ABCs).
Question: When managing a patient with acute cranial or cervical spine trauma,
what secondary musculoskeletal injuries must healthcare providers actively work
to prevent, and how?
✔✔ Answer: Providers must prevent secondary spinal cord damage, specifically
stabilizing the thoracic and lumbar vertebral regions. This is achieved by ensuring
the patient's entire spine is kept perfectly straight and in a strict midline position.
Question: Why is the coordination of nursing interventions handled differently for
patients recovering from a severe traumatic brain injury?
✔✔ Answer: Grouping or clustering nursing tasks together (cluster care) must be
avoided for TBI patients. Spacing out interventions prevents dangerous spikes in
intracranial pressure by minimizing overall sensory stimulation.
Question: What is the required therapeutic positioning for a patient diagnosed with
a traumatic brain injury?
✔✔ Answer: The patient's head and neck must be maintained in a neutral, midline
alignment to promote proper venous drainage from the brain.
Question: What type of environmental modifications should a nurse implement in
the room of a patient recovering from a head injury?
✔✔ Answer: The patient requires a low-stimulus, calm, and quiet environment to
keep
, Do NOT encourage coughing or deep breathing hourly as part of the plan of care
for a TBI patient -ANSWER ✔✔(this causes increased risk for ICP)
What is included in the plan of care for a TBI patient? -ANSWER ✔✔-
hyperoxygenate
-quiet environment
-avoid cluster care
What is a normal finding in TBI patient? -ANSWER ✔✔-amnesia at time of injury
-GCS score of 14
-photophobia
-balance and gait problems are consistent in TBI patients
What requires further intervention for a TBI patient (what is wrong) -ANSWER
✔✔-Do NOT encourage deep breathing or coughing (increases ICP)
-Do NOT do hip ROM exercises (need to be straight and midline)
-A widened pulse pressure is NOT consistent with TBI (intervention needed or
priority patient)
-Pupil changes are not expected and are an issue (brainstem issue)
which pt finding in skull fracture requires immediate MD notification? -ANSWER
✔✔becomes irritable and restlessness
What Glasgow coma scale is consistent with a TBI patient? -ANSWER ✔✔14
