NUR 265 exam 3 || 100% Detailed Answers.
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to notify
to PCP correct answers takes warfarin daily--there could be a hemorrhage as part of the injury.
warfarin is a blood thinner
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for ICP--what
action requires intervention? correct answers raising the foot of the pt beds-- maintain the head
midline/neutral position to prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ? correct
answers clustering pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse identity
as the greatest risk? correct answers 20 year old college student who is on the football team.
Nurse w assigned pts. which assessment finding would need to be reported to PCP? correct
answers the development of asymmetric pupils with no reaction to light in the pt who has a TBI--
pupillary changes;
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has rhinorrhea and it is
positive for glucose--what action is next? correct answers perform a halo sign test--CSG leaking,
lab test will be analyzed for glucose and electrolyte content. place fluid on a while absorbent
paper/linen
nurse providing dc teaching to pts partner who sustained a mild head injury from MVC. --what
statement requires additional teaching? correct answers I will bring my partner to the ED if they
immediately start vomiting--symptoms usually resolve within 72 hrs NV is expected.
Nurse is caring for the following pt. which pt would the nurse see first? correct answers the pt
who has a brain injury and a BP change from 110/58 to 134/40-- cushings triad. severe htn,
widening pulse pressure, bradycardia
, 24 hr post op craniotomy. pt is reporting headach 8/10-- what is the next step for the nurse to
take? correct answers perform a neuro assessment--minimize ICP, assess the problem.
sx of increased ICP= headache, deteriorating LOC, restlessness and irritability.
pt with encephalitis. what is the priority for the nurse to f/u on? correct answers has a change in
BP from 120/78 to 130/60--changes in vs that require immediate notification to HCP are a
widened pulse pressure, new bradycardia and irregular respiratory effort.
nurse caring for a pt who has been admitted with suspected bacterial meningitis. which action
should the nurse take first? correct answers Droplet precautions. prepare the client for a lumbar
puncture--most important test.
pt has confusion, fever, headache, blurred vision, NV, hx of HIV- what should the nurse do
FIRST? correct answers implement seizure precautions-- pt could have encephalitits dues to
HIV/fever, seizures are common
T5 SCI 6 months ago. s/s flushed face, profuse sweating, blurred vision, bp 145/95 hr68 95%--
what should the nurse do first? correct answers palpate the bladder--catheterize the pt with
autonomic dysreflexia to decrease the pressure. EMERGENT. severe htn. elevate HOB
pt admittd with SCI. what prescription would require f/u? correct answers mannitol- used to tx
ICP
dextran, atropine, dopamine are used for SCI
Dextran correct answers increased cap blood flow to tx hypotension
atropine correct answers tx reduce HR
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to notify
to PCP correct answers takes warfarin daily--there could be a hemorrhage as part of the injury.
warfarin is a blood thinner
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for ICP--what
action requires intervention? correct answers raising the foot of the pt beds-- maintain the head
midline/neutral position to prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ? correct
answers clustering pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse identity
as the greatest risk? correct answers 20 year old college student who is on the football team.
Nurse w assigned pts. which assessment finding would need to be reported to PCP? correct
answers the development of asymmetric pupils with no reaction to light in the pt who has a TBI--
pupillary changes;
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has rhinorrhea and it is
positive for glucose--what action is next? correct answers perform a halo sign test--CSG leaking,
lab test will be analyzed for glucose and electrolyte content. place fluid on a while absorbent
paper/linen
nurse providing dc teaching to pts partner who sustained a mild head injury from MVC. --what
statement requires additional teaching? correct answers I will bring my partner to the ED if they
immediately start vomiting--symptoms usually resolve within 72 hrs NV is expected.
Nurse is caring for the following pt. which pt would the nurse see first? correct answers the pt
who has a brain injury and a BP change from 110/58 to 134/40-- cushings triad. severe htn,
widening pulse pressure, bradycardia
, 24 hr post op craniotomy. pt is reporting headach 8/10-- what is the next step for the nurse to
take? correct answers perform a neuro assessment--minimize ICP, assess the problem.
sx of increased ICP= headache, deteriorating LOC, restlessness and irritability.
pt with encephalitis. what is the priority for the nurse to f/u on? correct answers has a change in
BP from 120/78 to 130/60--changes in vs that require immediate notification to HCP are a
widened pulse pressure, new bradycardia and irregular respiratory effort.
nurse caring for a pt who has been admitted with suspected bacterial meningitis. which action
should the nurse take first? correct answers Droplet precautions. prepare the client for a lumbar
puncture--most important test.
pt has confusion, fever, headache, blurred vision, NV, hx of HIV- what should the nurse do
FIRST? correct answers implement seizure precautions-- pt could have encephalitits dues to
HIV/fever, seizures are common
T5 SCI 6 months ago. s/s flushed face, profuse sweating, blurred vision, bp 145/95 hr68 95%--
what should the nurse do first? correct answers palpate the bladder--catheterize the pt with
autonomic dysreflexia to decrease the pressure. EMERGENT. severe htn. elevate HOB
pt admittd with SCI. what prescription would require f/u? correct answers mannitol- used to tx
ICP
dextran, atropine, dopamine are used for SCI
Dextran correct answers increased cap blood flow to tx hypotension
atropine correct answers tx reduce HR
