The client recovering from a head injury is arousable and participating in care. The
nurse determines that the client understands measures to prevent elevations in
intracranialpressure if the nurse observes the client doing which of the following
activities?
Blowing the nose
Isometricexercises
Coughing vigorously
Exhaling during repositioning
Give this one a try later!
Exhaling during repositioning
When the nurse is assessing victims in an emergency situation, what is the priority to
assess?
A. Hemorrhage
B. Fractures
,C. Mobility
D. Abnormal breathing
Give this one a try later!
D. Abnormal breathing
nurse is caring for several clients at risk for shock. Which laboratory values requires
the nurse to communicate with the healthcare provider?
Creatinine: 0.9 mg/dL
Lactate: 54 mg/dL
Sodium: 145 mEq/L
White Blood cell count: 11,000/mm3
Give this one a try later!
Lactate: 54 mg/dL
A client with a serious head injury with increased intracranial pressure is to be
discharged to a rehabilitation facility. Which outcome of rehab would be appropriate
for the client? The client will:
A. Exhibit no further episodes of short-term memory loss
B. Be able to return to his construction job in 3 weeks
C. Actively participate in the rehabilitation process as appropriate
D. Be emotionally stable and display preinjury personality traits
Give this one a try later!
C. Actively participate in the rehabilitation process as appropriate
,The nurse is evaluating the neurological signs of a client in spinal shock following
spinal cord injury. Which of the following observations by the nurse indicates that
spinal shock persisted?
Hyperreflexia
positivereflexes
reflex empty none of the bladder
flaccid paralysis
Give this one a try later!
flaccid paralysis
The nurse is caring for the client who begins to experience seizure activity while in
bed. Which of the following actions by the nurse would be contraindicated?
Loosening restrictive clothing
Restraining the clients limbs
Removing the pillow and raising padded side rails
Positioning the client to the side, if possible, with the head flexed forward
Give this one a try later!
Restraining the clients limbs
The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then
attempts to determine the cause of the alarm. The nurse is unsuccessful in
determining the cause of the alarm and takes what initial action?
Administers oxygen
Checks the client's vital signs
Ventilates the client manually
Starts cardiopulmonary resuscitation
, Give this one a try later!
Ventilates the client manually
A client arrives in the emergency department with an in shimek stroke. Because the
healthcare team is considering ministering tissue plasminogen activator )t-PA)
administration, the nurse should perform which of the following first?
Ask what medication the client is taking
complete a history and health assessment
identify the time of onset of the stroke
determine if the client is scheduled for any surgical procedures
Give this one a try later!
identify the time of onset of the stroke
The client with Guillain-Barre syndrome has ascending paralysis and is intubated and
receiving mechanical ventilation. Which of the following strategies would the nurse
incorporate in the plan of care to help the client cope with this illness?
Giving client full control over care decisions and restricting visitors
Providing positive feedback and encouraging active range of motion- pg 916
Providing information, giving positive feedback, and encouraging relaxation
Providing intravenously administered sedatives, reducing distractions, and
limiting visitors
Give this one a try later!
Providing information, giving positive feedback, and encouraging
relaxation
nurse determines that the client understands measures to prevent elevations in
intracranialpressure if the nurse observes the client doing which of the following
activities?
Blowing the nose
Isometricexercises
Coughing vigorously
Exhaling during repositioning
Give this one a try later!
Exhaling during repositioning
When the nurse is assessing victims in an emergency situation, what is the priority to
assess?
A. Hemorrhage
B. Fractures
,C. Mobility
D. Abnormal breathing
Give this one a try later!
D. Abnormal breathing
nurse is caring for several clients at risk for shock. Which laboratory values requires
the nurse to communicate with the healthcare provider?
Creatinine: 0.9 mg/dL
Lactate: 54 mg/dL
Sodium: 145 mEq/L
White Blood cell count: 11,000/mm3
Give this one a try later!
Lactate: 54 mg/dL
A client with a serious head injury with increased intracranial pressure is to be
discharged to a rehabilitation facility. Which outcome of rehab would be appropriate
for the client? The client will:
A. Exhibit no further episodes of short-term memory loss
B. Be able to return to his construction job in 3 weeks
C. Actively participate in the rehabilitation process as appropriate
D. Be emotionally stable and display preinjury personality traits
Give this one a try later!
C. Actively participate in the rehabilitation process as appropriate
,The nurse is evaluating the neurological signs of a client in spinal shock following
spinal cord injury. Which of the following observations by the nurse indicates that
spinal shock persisted?
Hyperreflexia
positivereflexes
reflex empty none of the bladder
flaccid paralysis
Give this one a try later!
flaccid paralysis
The nurse is caring for the client who begins to experience seizure activity while in
bed. Which of the following actions by the nurse would be contraindicated?
Loosening restrictive clothing
Restraining the clients limbs
Removing the pillow and raising padded side rails
Positioning the client to the side, if possible, with the head flexed forward
Give this one a try later!
Restraining the clients limbs
The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then
attempts to determine the cause of the alarm. The nurse is unsuccessful in
determining the cause of the alarm and takes what initial action?
Administers oxygen
Checks the client's vital signs
Ventilates the client manually
Starts cardiopulmonary resuscitation
, Give this one a try later!
Ventilates the client manually
A client arrives in the emergency department with an in shimek stroke. Because the
healthcare team is considering ministering tissue plasminogen activator )t-PA)
administration, the nurse should perform which of the following first?
Ask what medication the client is taking
complete a history and health assessment
identify the time of onset of the stroke
determine if the client is scheduled for any surgical procedures
Give this one a try later!
identify the time of onset of the stroke
The client with Guillain-Barre syndrome has ascending paralysis and is intubated and
receiving mechanical ventilation. Which of the following strategies would the nurse
incorporate in the plan of care to help the client cope with this illness?
Giving client full control over care decisions and restricting visitors
Providing positive feedback and encouraging active range of motion- pg 916
Providing information, giving positive feedback, and encouraging relaxation
Providing intravenously administered sedatives, reducing distractions, and
limiting visitors
Give this one a try later!
Providing information, giving positive feedback, and encouraging
relaxation
