GNRS 558: FINAL EXAM 2025-2026|ACTUAL
250Qs&As|GRADED A+|AZUSA PACIFIC UNIVERSITY
The nurse provides care for an adolescent client after a skateboard accident
that resulted in a brief episode of unconsicousness. The client's scalp and facial
lacerations were treated and dressed in the emergency department. which
nursing care measure is the HIGHEST priority?
1. change the head wound dressings.
2. perform neurological checks frequently.
3. administer antiemetic medications.
4. Manage the client's report of a headache.
2. perform neurological checks frequently.
The nurse provides care for a school-age client with a TBI. Which symptoms
best indicate IICP?
1. Headache, cring, sensitivity to loud noises and bright lights.
2. Widening pulse pressure, slowed respirations, bradycardia.
3. Hypotension, cyanosis, tachcardia.
4. Increased temperature, increase in respirations.
2. Widening pulse pressure, slowed respirations, bradycardia.
,The nurse provides care for a client diagnosed with a closed head injury and
IICP. Whichaction by the nurse is best?
1. Position the clinet with head of bed flat and cleint's head in a neutral
positon.
2. Instruct client to exhale when turning or moving in bed.
3. Encourage client to cough and deep breathe every two hours.
4. Suciton client frequently and hyperoxygenate prior to suctioning.
2. Instruct client to exhale when turning or moving in bed.
The nurse provides care for a client with expressive aphasia due to dysarthria
from a stroke. Which techniqu is most appropriate for the nurse to use when
helping the client communicate?
1. Speaking slowly and with a raised volume
2.Encouraging the client to use gestures
3. Allowing the client to speak in short phrases.
4. reminding the client to swallow before speaking
3. Allowing the client to speak in short phrases.
The nurse provides care for a client admitted to the emergency department
following an autoobile accident. The client reports dizziness, and th health care
provider suspects a head injury. The nurse intervenes if which activity is
observed?
1. The client is placed in trendelenburg position.
2. the clien'ts neck is immobilized prior to being X-rayed
3. The nursing staff frequently monitors the client's level of consciousness.
,4. The nursing staff observes for seizures.
1. The client is placed in trendelenburg position.
An unconscious client arrives in the emergency department following a fall
that resulted in a severe head injury. Which action does the nurse take first?
1. Assess the patency of the airway.
2. Check the client's pupils for size and reaction to light.
3. Establish the clien'ts LOC
4. evaluate the client's motor response
1. Assess the patency of the airway.
The nurse notes a client is able to open the eyes spontaneously, follow
command to hold up two fingers, and correclty identify the day of the week
and current location. Using the GCS, which score does the nurse correctly
assign to the client?
1. 3
2. 6
3. 10
4. 15
4. 15
The nurse assesses for signs associated with IICP in a client diagnosed with a
subdural hematoma. Which is the earliest sign of an increase in ICP?
, 1. a change in LOC
2. a widening pulse pressure
3. bradycardia
4. decorticate position
1. a change in LOC
The nurse assess a client diagnosed with cerebral contusion and IICP. Which is
the correct initial nursing aciton?
1. Placing a footboard to decrease foot drop.
2. Encouraging head movement to the right.
3. Elevating HOB 15-30 degrees
4. Suctioning q2h to maintain the airway
3. Elevating HOB 15-30 degrees
The nurse provides care for a child diagnosed with a serious closed head
injury. The client's parent says to the nurse, "Will my child be all right? Is my
child going to die? I'm so scared" Which response by the nurse is the best?
1. "of course your child will be all right. It will take time for your child to get
better."
2. "I'll be avaiable if you have any questions. Here is a booklet on head
injuries"
3. It must be frightening to see your child hurt.
4. "Its too soon to know the outcome. Would you like to talk with the HCP?
3. It must be frightening to see your child hurt.
250Qs&As|GRADED A+|AZUSA PACIFIC UNIVERSITY
The nurse provides care for an adolescent client after a skateboard accident
that resulted in a brief episode of unconsicousness. The client's scalp and facial
lacerations were treated and dressed in the emergency department. which
nursing care measure is the HIGHEST priority?
1. change the head wound dressings.
2. perform neurological checks frequently.
3. administer antiemetic medications.
4. Manage the client's report of a headache.
2. perform neurological checks frequently.
The nurse provides care for a school-age client with a TBI. Which symptoms
best indicate IICP?
1. Headache, cring, sensitivity to loud noises and bright lights.
2. Widening pulse pressure, slowed respirations, bradycardia.
3. Hypotension, cyanosis, tachcardia.
4. Increased temperature, increase in respirations.
2. Widening pulse pressure, slowed respirations, bradycardia.
,The nurse provides care for a client diagnosed with a closed head injury and
IICP. Whichaction by the nurse is best?
1. Position the clinet with head of bed flat and cleint's head in a neutral
positon.
2. Instruct client to exhale when turning or moving in bed.
3. Encourage client to cough and deep breathe every two hours.
4. Suciton client frequently and hyperoxygenate prior to suctioning.
2. Instruct client to exhale when turning or moving in bed.
The nurse provides care for a client with expressive aphasia due to dysarthria
from a stroke. Which techniqu is most appropriate for the nurse to use when
helping the client communicate?
1. Speaking slowly and with a raised volume
2.Encouraging the client to use gestures
3. Allowing the client to speak in short phrases.
4. reminding the client to swallow before speaking
3. Allowing the client to speak in short phrases.
The nurse provides care for a client admitted to the emergency department
following an autoobile accident. The client reports dizziness, and th health care
provider suspects a head injury. The nurse intervenes if which activity is
observed?
1. The client is placed in trendelenburg position.
2. the clien'ts neck is immobilized prior to being X-rayed
3. The nursing staff frequently monitors the client's level of consciousness.
,4. The nursing staff observes for seizures.
1. The client is placed in trendelenburg position.
An unconscious client arrives in the emergency department following a fall
that resulted in a severe head injury. Which action does the nurse take first?
1. Assess the patency of the airway.
2. Check the client's pupils for size and reaction to light.
3. Establish the clien'ts LOC
4. evaluate the client's motor response
1. Assess the patency of the airway.
The nurse notes a client is able to open the eyes spontaneously, follow
command to hold up two fingers, and correclty identify the day of the week
and current location. Using the GCS, which score does the nurse correctly
assign to the client?
1. 3
2. 6
3. 10
4. 15
4. 15
The nurse assesses for signs associated with IICP in a client diagnosed with a
subdural hematoma. Which is the earliest sign of an increase in ICP?
, 1. a change in LOC
2. a widening pulse pressure
3. bradycardia
4. decorticate position
1. a change in LOC
The nurse assess a client diagnosed with cerebral contusion and IICP. Which is
the correct initial nursing aciton?
1. Placing a footboard to decrease foot drop.
2. Encouraging head movement to the right.
3. Elevating HOB 15-30 degrees
4. Suctioning q2h to maintain the airway
3. Elevating HOB 15-30 degrees
The nurse provides care for a child diagnosed with a serious closed head
injury. The client's parent says to the nurse, "Will my child be all right? Is my
child going to die? I'm so scared" Which response by the nurse is the best?
1. "of course your child will be all right. It will take time for your child to get
better."
2. "I'll be avaiable if you have any questions. Here is a booklet on head
injuries"
3. It must be frightening to see your child hurt.
4. "Its too soon to know the outcome. Would you like to talk with the HCP?
3. It must be frightening to see your child hurt.
