NUR390 / NUR 390 EXAM 3 Nursing Care of Adult I Concordia, St. Paul Actual Questions and Answers

NUR390 / NUR 390 EXAM 3 Nursing Care of Adult I Concordia, St. Paul Actual Questions and Answers. 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 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 procedures to them. d. Refer the family members to the hospital counseling service to deal with their anxiety. Answer c. Allow the family to stay with the patient and briefly explain all procedures to them. A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods. Answer c. Keep the head of the bed elevated to 30 degrees. 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 20-yr-old is admitted with a head injury after a collision while playing sports. After noting that the patient has developed clear nasal drainage, which action would the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorthea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity. Answer b. Check the drainage for glucose content. Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Arrange to admit the patient to the neurologic unit for observation. d. Transport the patient to radiology for magnetic resonance imaging (MRI). Answer b. Provide discharge instructions about monitoring neurologic status. A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.