NUR 245 Exam 1 UPDATED ACTUAL QUESTIONS AND CORRECT ANSWERS
Mental status changes (this can be a brain bleed) If a patient had a stroke and is receiving thrombolytic therapy (TPA) what is
important to monitor the patient for?
Neuro checks If a patient has a carotid stent placed what kind of assessments would you
Watch for stroke symptoms perform?
Can reclot
How long have they had symptoms? If a patient comes to the ER and is having symptoms of a stroke what would you
Did it start with a SUDDEN severe headache? ask them before administering aspirin?
asterixis (flapping tremors)This may take several What is a characteristic manifestation of hepatic encephalopathy?
formsMost common involve arms and hands**When
asked to hold the arms and hands stretched out, the
patient ins unable to hold this position and performs a
series of rapid flexion and extension movements of the
hands.
to lower ammonia levels Why do we give lactulose to a patient with hepatic encephalopathy?
ICP If you see a patient with postauricular eccymosis what kind of injury do you think
head injury they had?
Lumbar puncture If a patient has ICP what should you never do?
, Portal hypertension What causes ascites?
hypoalbuminemia
Albumin levels If you are assessing a cirrhosis patient and they have +3/4 edema what should you
check?
Low protein If a patient has an elevated ammonia level what kind of diet should they be on?
Jaundice If a patient has elevated billirubin levels what kinds of signs and symptoms would
Clay colored stools they have?
You would perform the glasgow coma scale How would you perform a neuro status check on a patient with a head injury?
Nothing, just document that they are alert and oriented If a patient Glasgow coma scale score is 15 what would the nurse do?
8 and below is bad
they would have mental status changes A patient is in the hospital and was diagnosed with ICP how can you tell that their
cranial pressure is increasing?
1. Fatty Streak (Reversible) What are the stages of atherosclerosis (CAD)?
2. Fibrous Plaque
3. Complicated Lesion
elevate the head of the bed to 30 degrees What nursing interventions would you perform on a patient with ICP?
head and neck midline with body
quiet/dark room - reduce activity-reduce stimulation
NEVER cluster care
2-3 What is therapeutic INR range?
Fresh frozen plasma What can you give to a patient that is going into DIC?
Soft bristled toothbrush What would you teach a patient that has thrombocytopenia?
electric razor
wear gloves when gardening
Turn off Heparin Patient had normal platelet count >150k before starting Heparin therapy. Soon
Call Dr. after starting the drug their platelet count dropped to 100k. What would the nurse
Put Heparin as an Allergy in pt's chart do?
More prone to blood clots Virchow's triad
3 FACTORS
**HYPERCOAGUABILITY OF BLOOD
INJURY TO THE VESSEL WALL
STASIS OF BLOOD FLOW
Mental status changes (this can be a brain bleed) If a patient had a stroke and is receiving thrombolytic therapy (TPA) what is
important to monitor the patient for?
Neuro checks If a patient has a carotid stent placed what kind of assessments would you
Watch for stroke symptoms perform?
Can reclot
How long have they had symptoms? If a patient comes to the ER and is having symptoms of a stroke what would you
Did it start with a SUDDEN severe headache? ask them before administering aspirin?
asterixis (flapping tremors)This may take several What is a characteristic manifestation of hepatic encephalopathy?
formsMost common involve arms and hands**When
asked to hold the arms and hands stretched out, the
patient ins unable to hold this position and performs a
series of rapid flexion and extension movements of the
hands.
to lower ammonia levels Why do we give lactulose to a patient with hepatic encephalopathy?
ICP If you see a patient with postauricular eccymosis what kind of injury do you think
head injury they had?
Lumbar puncture If a patient has ICP what should you never do?
, Portal hypertension What causes ascites?
hypoalbuminemia
Albumin levels If you are assessing a cirrhosis patient and they have +3/4 edema what should you
check?
Low protein If a patient has an elevated ammonia level what kind of diet should they be on?
Jaundice If a patient has elevated billirubin levels what kinds of signs and symptoms would
Clay colored stools they have?
You would perform the glasgow coma scale How would you perform a neuro status check on a patient with a head injury?
Nothing, just document that they are alert and oriented If a patient Glasgow coma scale score is 15 what would the nurse do?
8 and below is bad
they would have mental status changes A patient is in the hospital and was diagnosed with ICP how can you tell that their
cranial pressure is increasing?
1. Fatty Streak (Reversible) What are the stages of atherosclerosis (CAD)?
2. Fibrous Plaque
3. Complicated Lesion
elevate the head of the bed to 30 degrees What nursing interventions would you perform on a patient with ICP?
head and neck midline with body
quiet/dark room - reduce activity-reduce stimulation
NEVER cluster care
2-3 What is therapeutic INR range?
Fresh frozen plasma What can you give to a patient that is going into DIC?
Soft bristled toothbrush What would you teach a patient that has thrombocytopenia?
electric razor
wear gloves when gardening
Turn off Heparin Patient had normal platelet count >150k before starting Heparin therapy. Soon
Call Dr. after starting the drug their platelet count dropped to 100k. What would the nurse
Put Heparin as an Allergy in pt's chart do?
More prone to blood clots Virchow's triad
3 FACTORS
**HYPERCOAGUABILITY OF BLOOD
INJURY TO THE VESSEL WALL
STASIS OF BLOOD FLOW
