NUR 265 Exam 3 Review Questions
and Answers Latest Update
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to notify to PCP -
Correct Answer: takes warfarin daily--there could be a hemorrhage as part of the injury. warfarin is a
blood thinner
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for ICP--what action
requires intervention? - Correct Answer: raising the foot of the pt beds-- maintain the head
midline/neutral position to prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ? - Correct Answer:
clustering pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse identity as the
greatest risk? - Correct Answer: 20 year old college student who is on the football team.
Nurse w assigned pts. which assessment finding would need to be reported to PCP? - Correct Answer:
the development of asymmetric pupils with no reaction to light in the pt who has a TBI-- pupillary
changes;
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has rhinorrhea and it is
positive for glucose--what action is next? - Correct Answer: perform a halo sign test--CSG leaking, lab
test will be analyzed for glucose and electrolyte content. place fluid on a while absorbent paper/linen
nurse providing dc teaching to pts partner who sustained a mild head injury from MVC. --what
statement requires additional teaching? - Correct Answer: I will bring my partner to the ED if they
immediately start vomiting--symptoms usually resolve within 72 hrs NV is expected.
Nurse is caring for the following pt. which pt would the nurse see first? - Correct Answer: the pt who has
a brain injury and a BP change from 110/58 to 134/40-- cushings triad. severe htn, widening pulse
pressure, bradycardia
and Answers Latest Update
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to notify to PCP -
Correct Answer: takes warfarin daily--there could be a hemorrhage as part of the injury. warfarin is a
blood thinner
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for ICP--what action
requires intervention? - Correct Answer: raising the foot of the pt beds-- maintain the head
midline/neutral position to prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ? - Correct Answer:
clustering pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse identity as the
greatest risk? - Correct Answer: 20 year old college student who is on the football team.
Nurse w assigned pts. which assessment finding would need to be reported to PCP? - Correct Answer:
the development of asymmetric pupils with no reaction to light in the pt who has a TBI-- pupillary
changes;
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has rhinorrhea and it is
positive for glucose--what action is next? - Correct Answer: perform a halo sign test--CSG leaking, lab
test will be analyzed for glucose and electrolyte content. place fluid on a while absorbent paper/linen
nurse providing dc teaching to pts partner who sustained a mild head injury from MVC. --what
statement requires additional teaching? - Correct Answer: I will bring my partner to the ED if they
immediately start vomiting--symptoms usually resolve within 72 hrs NV is expected.
Nurse is caring for the following pt. which pt would the nurse see first? - Correct Answer: the pt who has
a brain injury and a BP change from 110/58 to 134/40-- cushings triad. severe htn, widening pulse
pressure, bradycardia
