EXAM 3 PRACTICE QUESTIONS & RATIONALES FOR NUR 265: COMPLEX MOBILITY & COGNITION COMPLETE

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EXAM 3 PRACTICE QUESTIONS & RATIONALES FOR NUR 265:
COMPLEX MOBILITY & COGNITION COMPLETE

1.) The nurse is caring for an adult client who was recently admitted with a head injury foll
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owing a motor vehicle crash. One hour ago, the client's vital signs (VS) were temperature (T
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): 98.6° F; pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which o
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f the following findings is a priority for the nurse to follow up?
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P: 90; R: 32; BP: 130/72 mm Hg.-
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P: 120; R: 26, BP: 110/70 mm_ Hg. P:
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56; R: 14; BP: 166/52 mm Hg. qw qw qw qw qw qw




P: 64, R: 30; BP: 148/78m Hg.
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2.) The nurse is caring for a client who sustained a closed head injury, is receiving mechanic
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al ventilation, and is at risk for developing increased intracranial pressure (ICP). Which of t
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he following actions should the nurse take when caring for this client?
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Perform passive range of motion (ROM) to the client's hips and knees. Log ro qw qw qw qw qw qw qw qw qw qw qw qw qw




ll the client during turning and repositioning.
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Elevate the foot of the client's bed. qw qw qw qw qw qw




Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
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3.) The newly hired nurse is caring for a client who was admitted 12 hours ago with a traum
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atic brain injury (TBI), is intubated, and is at risk for developing increased intracranial pre
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ssure (ICP). qw




Which interventions from the box below should the nurse include in the client's plan of car
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e?
1 Avoid clustering client care activities. qw qw qw qw




2 Maintain the head in a flexed position. qw qw qw qw qw qw




3 Provide a quiet environment by limiting visitors. qw qw qw qw qw qw




4 Have the client cough and deep breathe every hour. qw qw q w q w qw qw qw qw




5 Hyper oxygenate the client before and after suctioning. qw qw qw qw qw qw qw




6. Avoid maintaining hips in a flexed position. qw qw qw qw qw qw




1, 3, 4, 5. qw qw qw




1, 3, 5, 6. qw qw qw




1, 2, 4, 6. qw qw qw




2, 4, 6. qw qw




4.) The nurse working in the intensive care unit (ICU) is assessing a client who sustained a
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basilar skull fracture 24 hours ago. It is most important to follow up with the primary healt
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h care provider (PHCP) if the client
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becomes irritable and restless. has qw qw qw qw qw




bruises under the eyes. qw qw qw




is unable to name the state capital.
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reports having a persistent headache since admission. q w q w q w q w q w q w

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5.) The nurse is assessing a client who has experienced a mild traumatic brain injury (TBI)
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. Which findings from the box below are consistent with this diagnosis?
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1 Dizziness and gait problems. q w q w q w




2 A widened pulse pressure. qw qw qw




3 Increased sensitivity to light or noise. q w q w q w q w q w




4 AGlasgowComaScale(GCS)scoreof9. w
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5 Dilated pupils that are nopreactive to light. qw qw qw qw qw qw




6 Amnesia about the events around the time of injury. qw qw qw qw qw qw qw qw




1, 3, 6. qw qw




3, 5, 6. qw qw




2, 3, 4, 5. qw qw qw




1, 2, 4, 6. qw qw qw




6.) The nurse is providing discharge instructions to the parents of a 15-year-
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old female who sustained a concussion while plaving field back
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Which of the following statements by a parent indicates a need for further teaching?
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"We should avoid giving any acetaminophen to treat headaches.
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"We need to bring our daughter back te the emergency department if she exhibits blurred vision."
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"We should provide a consistent routine at home to assist with any behavior changes." "We wil
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l not allow our daughter to engage in strenuous activity for at least 48 hours."
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7.) The nurse is assessing clients for the risk of sustaining a traumatic brain injury (TBI).
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Which of the following clients should the nurse identify as being at greatest risk?
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45-year-old who has epilepsy and takes phenytoin. q w q w q w q w q w q w




75-year-old who lives alone and has macular degeneration. q w q w q w q w q w q w q w




7-year-old who is learning how to ride a bicycle without training wheels. 20- qw qw qw qw qw qw qw qw qw qw qw qw




year-old college student who participates on the tennis team. qw qw qw qw qw qw qw qw




8.) The nurse is providing discharge instructions to the partner of a client who sust
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ained a mild head injury as a result of a motor vehicle crash. Which of the following
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statements by a partner indicates a need for farther teaching? qw qw qw qw qw qw qw qw qw




"It is expected that my partner will have drainage from the nose for the next few days." "I will p
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rovide my partner with aeetaminophen every 4 hours for headache."
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"I will ensure my partner avoids strenuous activity for the next 48 hours."
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"I will avoid giving my partner their scheduled lorazepam for at least the next 24 hours."
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9.) The nurse is caring for a client who is postoperative following a craniotomy and has dev
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eloped syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following a
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ctions should the purse take? qw qw qw qw




Remove salt packets from the client's meal tray. qw q w q w q w q w q w q w




Change IV fluids to 0.45% sodium chloride (half-qw qw qw qw qw qw qw




strength saline). Initiate a prescribed fluid restriction. qw qw qw qw qw qw




Administer oral desmopressin acetate. q w q w q w




10.) The nurse is caring for the following assigned clients. Which client should the nurs
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e see first?
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The client who has bacterial meningitis and has become lethargic.
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The client who has a mild traumatic brain injury (BI) and is reporting dizziness and insomnia.
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The client who has a concussion and is irritable and reporting a headache.
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The client who has a skull fracture, is alert and oriented, and reports feeling nauseated.
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11.) The nurse is caring for a client who has meningitis. It is a priority for the nurse to follow
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up if qw




reports the development of fatigue. qw qw qw qw




hasa change in Glasgow Coma Scale (GCS)score from 12 to 14 over the past 4 hours.
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has a change in blood pressure (BP) from 132/75 to 160/56 mm Hg. reports s
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ensitivity to light. qw qw




12.) The nurse is admitting a client who is diagnosed with bacterial meningitis. Which of th
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e following actions should the nurse take first?
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Assess the eyes for pupillary shape and movement. Teach
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the client about the condition and treatment.
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Determine who the client has been in contact with. Adminis qw qw qw qw qw qw qw qw q w




ter an antiepileptic medication.
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13.) The nurse working in the emergency department (ED) is admitting a client who is a coll
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ege student and lives in a dormitory. The client has chills, nuchal rigidity, and a
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