Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
1. The nurse is working in the emergency department takes prescribed warfarin
and is admitting a client who has a sustained TBI, daily
following a motor vehicle crash, it is a priority for the
nurse to notify the primary health care provider if the
client
2. The charge nurse observes a newly hired nurse caring raising the foot of the
for a client who sustained a closed head clients bed
injury, is receiving mechanical ventilation, and is at risk
for developing ICP. Which of the following
actions, if performed by the newly hired nurse, re-
quires intervention by the charge nurse?
3. The newly hired nurse is caring for a client who was Clustering client care activ-
admitted 12 hours ago with a TBI and is at risk ities
for developing ICP. It requires intervention by the
nurse preceptor if the newly hired nurse is observed
4. The nurse is assessing clients for the risk of sustaining 20 yr old college student
TBI. Which of the following clients should who participates on the
the nurse identify as being at greatest risk? football team
5. The nurse is caring for assigned clients. Which of the the development of asym-
following assessment findings requires the metric pupils with no re-
nurse to notify the PHCP? action to light in the client
who has the TBI
6. The nurse is caring for a client with a TBI and a skull Perform a halo sign test
fracture. The nurse noted that the client had
developed rhinorrhea (nasal drip) positive for glucose.
Which of the following actions should the
nurse take next?
1/8
, Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
7. The nurse is providing discharge instructions to a i will bring my partner to
client's partner who sustained a mild head the ED if they immediately
injury due to an MVA. Which of the following state- starting vomiting
ments, if made by the partners, would indicate
the need for additional teaching?
8. The nurse is caring for the following assigned clients. The client who has brain
Which client should the nurse see first? injusry and bp change
from 110/58 to 134/40
9. The nurse is caring for a client who is 24 hours post-op Perform a neurological
following a craniotomy. The client is test
reporting a headache that is rated as an 8 on a scale of
0-10 pain scale. Which of the following actions should
the nurse take?
10. The nurse is caring for a client who has encephalitis. It has a change in BP from
is priority for the nurse to follow up if the 120/78 to 130/60
client
11. The nurse is caring for a client who has been admitted Prepare the client for a
with suspected bacterial meningitis. Which lumbar puncture
of the following actions should the nurse take first?
12. The nurse is caring for the client who has confusion, implement seizure pre-
fever, headache, blurred vision, NV, and a cautions
history of HIV. Which of the following actions should
the nurse take first?
13. Findings: T5 SCI 6 months ago, flushed face, profuse palpate the clients bladder
sweating, reports blurred vision, BP 145/95, (Autonomic dysreflexia)
HR 68, O2 95%. Which of the following actions should
the nurse take?
2/8
Study online at https://quizlet.com/_d8r6jq
1. The nurse is working in the emergency department takes prescribed warfarin
and is admitting a client who has a sustained TBI, daily
following a motor vehicle crash, it is a priority for the
nurse to notify the primary health care provider if the
client
2. The charge nurse observes a newly hired nurse caring raising the foot of the
for a client who sustained a closed head clients bed
injury, is receiving mechanical ventilation, and is at risk
for developing ICP. Which of the following
actions, if performed by the newly hired nurse, re-
quires intervention by the charge nurse?
3. The newly hired nurse is caring for a client who was Clustering client care activ-
admitted 12 hours ago with a TBI and is at risk ities
for developing ICP. It requires intervention by the
nurse preceptor if the newly hired nurse is observed
4. The nurse is assessing clients for the risk of sustaining 20 yr old college student
TBI. Which of the following clients should who participates on the
the nurse identify as being at greatest risk? football team
5. The nurse is caring for assigned clients. Which of the the development of asym-
following assessment findings requires the metric pupils with no re-
nurse to notify the PHCP? action to light in the client
who has the TBI
6. The nurse is caring for a client with a TBI and a skull Perform a halo sign test
fracture. The nurse noted that the client had
developed rhinorrhea (nasal drip) positive for glucose.
Which of the following actions should the
nurse take next?
1/8
, Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
7. The nurse is providing discharge instructions to a i will bring my partner to
client's partner who sustained a mild head the ED if they immediately
injury due to an MVA. Which of the following state- starting vomiting
ments, if made by the partners, would indicate
the need for additional teaching?
8. The nurse is caring for the following assigned clients. The client who has brain
Which client should the nurse see first? injusry and bp change
from 110/58 to 134/40
9. The nurse is caring for a client who is 24 hours post-op Perform a neurological
following a craniotomy. The client is test
reporting a headache that is rated as an 8 on a scale of
0-10 pain scale. Which of the following actions should
the nurse take?
10. The nurse is caring for a client who has encephalitis. It has a change in BP from
is priority for the nurse to follow up if the 120/78 to 130/60
client
11. The nurse is caring for a client who has been admitted Prepare the client for a
with suspected bacterial meningitis. Which lumbar puncture
of the following actions should the nurse take first?
12. The nurse is caring for the client who has confusion, implement seizure pre-
fever, headache, blurred vision, NV, and a cautions
history of HIV. Which of the following actions should
the nurse take first?
13. Findings: T5 SCI 6 months ago, flushed face, profuse palpate the clients bladder
sweating, reports blurred vision, BP 145/95, (Autonomic dysreflexia)
HR 68, O2 95%. Which of the following actions should
the nurse take?
2/8
