Adult Health 1 Exam 3 Review
For Chapter 63 Management of
Patients with Neurologic
Trauma.
The emergency room (ER) nurse is caring for a client who has been
brought in by ambulance after sustaining a fall at home. What physical
assessment finding(s) are suggestive of a basilar skull fracture? Select
all that apply
A. Epistaxis
B. Swelling of the tongue and lips
,C. Bruising over the mastoid
D. Unilateral facial numbness
E. Severe back pain - ANSWER ✔✔A. Epistaxis
C. Bruising over the mastoid
A client is brought to the trauma center by ambulance after sustaining a
high cervical spinal cord injury 1½ hours ago. Endotracheal intubation
has been deemed necessary and the nurse is preparing to assist. What
nursing diagnosis should the nurse associate with this procedure?
A. Risk for impaired skin integrity
B. Risk for injury
C. Risk for autonomic dysreflexia
D. Risk for suffocation - ANSWER ✔✔D. Risk for suffocation
A nurse is caring for a critically ill client with autonomic dysreflexia. What
clinical manifestations would the nurse expect in this client?
A. Respiratory distress and projectile vomiting
B. Bradycardia and hypertension
, C. Tachycardia and agitation
D. Third-spacing and hyperthermia - ANSWER ✔✔B) Bradycardia
and hypertension
The nurse is caring for a client with increased intracranial pressure (ICP)
caused by a traumatic brain injury. Which of the following clinical
manifestations would suggest that the client may be experiencing
increased brain compression causing brain stem damage?
A. Hyperthermia
B. Tachycardia
C. Hypertension
D. Bradypnea - ANSWER ✔✔A. Hyperthermia
A client is brought to the ED by family after falling off the roof. The care
team suspects an epidural hematoma, prompting the nurse to anticipate
for which priority intervention?
A. Insertion of an intracranial monitoring device
B. Treatment with antihypertensives
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STATEMENT. ALL RIGHTS RESERVED
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For Chapter 63 Management of
Patients with Neurologic
Trauma.
The emergency room (ER) nurse is caring for a client who has been
brought in by ambulance after sustaining a fall at home. What physical
assessment finding(s) are suggestive of a basilar skull fracture? Select
all that apply
A. Epistaxis
B. Swelling of the tongue and lips
,C. Bruising over the mastoid
D. Unilateral facial numbness
E. Severe back pain - ANSWER ✔✔A. Epistaxis
C. Bruising over the mastoid
A client is brought to the trauma center by ambulance after sustaining a
high cervical spinal cord injury 1½ hours ago. Endotracheal intubation
has been deemed necessary and the nurse is preparing to assist. What
nursing diagnosis should the nurse associate with this procedure?
A. Risk for impaired skin integrity
B. Risk for injury
C. Risk for autonomic dysreflexia
D. Risk for suffocation - ANSWER ✔✔D. Risk for suffocation
A nurse is caring for a critically ill client with autonomic dysreflexia. What
clinical manifestations would the nurse expect in this client?
A. Respiratory distress and projectile vomiting
B. Bradycardia and hypertension
, C. Tachycardia and agitation
D. Third-spacing and hyperthermia - ANSWER ✔✔B) Bradycardia
and hypertension
The nurse is caring for a client with increased intracranial pressure (ICP)
caused by a traumatic brain injury. Which of the following clinical
manifestations would suggest that the client may be experiencing
increased brain compression causing brain stem damage?
A. Hyperthermia
B. Tachycardia
C. Hypertension
D. Bradypnea - ANSWER ✔✔A. Hyperthermia
A client is brought to the ED by family after falling off the roof. The care
team suspects an epidural hematoma, prompting the nurse to anticipate
for which priority intervention?
A. Insertion of an intracranial monitoring device
B. Treatment with antihypertensives
COPYRIGHT©NINJANERD 2025/2026. YEAR PUBLISHED 2026. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
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