resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steri-strips. Which signs/symptoms warrant transferring the resident to the ED
Selected Answer:
B. A weak pulse, shallow respiration's, and cool pale skin
Answers:A. A 4 cm area of bright red drainage on the dressing
B. A weak pulse, shallow respiration's, and cool pale skin
C. Pupils that are equal, react to light, and accommodate
D. Complains of a headache that resolves with medication
Question 2
1 out of 1 points
The nurse is caring for several patients. Which patient would the nurse assess first after receiving the shift report
Selected Answer:
C. The 45 y/o patient admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale of 6
Answers:A. The 22 y/o male patient diagnosed with a concussion who is complaining
someone woke him up every 2 hours
B. The 36 y/o female patient admitted with c/o left sided weakness and is scheduled for an MRI
C. The 45 y/o patient admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale of 6
D. The 62 y/o patient diagnosed with a CVA who has expressive aphasia
Question 3
1 out of 1 points
The patient is admitted to the medical floor with a diagnosis of closed head injury. Which
nursing intervention has priority Selected Answer:
D. Maintain an adequate airway
Answers:A. Assess neurological status
B. Monitor vital signs
C. Initiate IV access
D. Maintain an adequate airway
Question 4
0 out of 1 points
The nurse is caring for a patient diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement (select all tha apply)
Selected Answers:
A. Maintain the head of the bed at 60 degrees of
elevation
B. Administer stool softners
C. Ensure the pulse oximeter reading is higher than 93%
Answers:A. Maintain the head of the bed at 60 degrees of
elevation
B. Administer stool softners
C. Ensure the pulse oximeter reading is higher than 93%
D. Perform deep nasal suction every 2 hours
E. Administer mild sedatives
Question 5
1 out of 1 points
The patient with a closed head injury has clear fluid drainage from the nose. Which action should the nurse implement first?
Selected Answer:
C. T est the drainage for the presence of glucose
Answers:A. Notify the provider
B. Prepare to administer an antihistamine
C. T est the drainage for the presence of glucose
D. Place a 2x2 gauze under the nose to collect the drainage
Question 6
0 out of 1 points
The 28 y/o patient is on the rehab unit post spinal cord injury at T10. Which collaborative team members should participate with the nurse at the case conference (select all that apply )
Selected Answers:
A. Occupational Therapist
B. Physical Therapist
D. Rehabilitation physician
F . Patient care tech
Answers:
A. Occupational Therapist
B. Physical Therapist
C. Registered Dietician
D. Rehabilitation physician
E. Social worker
F . Patient care tech
Question 7
0 out of 1 points
The patient is prescribed a loading does of phenytoin 15 mg/kg IV for seizure activity, then 100 mg IV tid. The patient weighs 198 lb. How many milligrams should the nurse administer for the loading dose (record your answer as a whole number)
Selected Answer: 10
5
Correct Answer:
Evaluation Method Correct Answer
Exact Match 1350
Question 8
1 out of 1 points
The nurse is administering mannitol IV to decrease the patient's ICP following a craniotomy. Which lab test result should the nurse monitor
Selected Answer:
A. Serum osmolarity
Answers:
A. Serum osmolarity
B. White blood cell count
C. Serum cholesterol
D. ESR
Question 9
1 out of 1 points
The nurse is assessing the patient after sustaining a closed head injury. When applying nailbed pressure the patient's body stiffens, the eyes roll upward, and there is increased salivation and a loss of swallowing reflex. Which observation should the nurse document
Selected Answer:
D. T onic seizure activity
Answers:A. Decerebrate posturing
B. Decorticate posturing
C.
Selected Answer:
B. A weak pulse, shallow respiration's, and cool pale skin
Answers:A. A 4 cm area of bright red drainage on the dressing
B. A weak pulse, shallow respiration's, and cool pale skin
C. Pupils that are equal, react to light, and accommodate
D. Complains of a headache that resolves with medication
Question 2
1 out of 1 points
The nurse is caring for several patients. Which patient would the nurse assess first after receiving the shift report
Selected Answer:
C. The 45 y/o patient admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale of 6
Answers:A. The 22 y/o male patient diagnosed with a concussion who is complaining
someone woke him up every 2 hours
B. The 36 y/o female patient admitted with c/o left sided weakness and is scheduled for an MRI
C. The 45 y/o patient admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale of 6
D. The 62 y/o patient diagnosed with a CVA who has expressive aphasia
Question 3
1 out of 1 points
The patient is admitted to the medical floor with a diagnosis of closed head injury. Which
nursing intervention has priority Selected Answer:
D. Maintain an adequate airway
Answers:A. Assess neurological status
B. Monitor vital signs
C. Initiate IV access
D. Maintain an adequate airway
Question 4
0 out of 1 points
The nurse is caring for a patient diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement (select all tha apply)
Selected Answers:
A. Maintain the head of the bed at 60 degrees of
elevation
B. Administer stool softners
C. Ensure the pulse oximeter reading is higher than 93%
Answers:A. Maintain the head of the bed at 60 degrees of
elevation
B. Administer stool softners
C. Ensure the pulse oximeter reading is higher than 93%
D. Perform deep nasal suction every 2 hours
E. Administer mild sedatives
Question 5
1 out of 1 points
The patient with a closed head injury has clear fluid drainage from the nose. Which action should the nurse implement first?
Selected Answer:
C. T est the drainage for the presence of glucose
Answers:A. Notify the provider
B. Prepare to administer an antihistamine
C. T est the drainage for the presence of glucose
D. Place a 2x2 gauze under the nose to collect the drainage
Question 6
0 out of 1 points
The 28 y/o patient is on the rehab unit post spinal cord injury at T10. Which collaborative team members should participate with the nurse at the case conference (select all that apply )
Selected Answers:
A. Occupational Therapist
B. Physical Therapist
D. Rehabilitation physician
F . Patient care tech
Answers:
A. Occupational Therapist
B. Physical Therapist
C. Registered Dietician
D. Rehabilitation physician
E. Social worker
F . Patient care tech
Question 7
0 out of 1 points
The patient is prescribed a loading does of phenytoin 15 mg/kg IV for seizure activity, then 100 mg IV tid. The patient weighs 198 lb. How many milligrams should the nurse administer for the loading dose (record your answer as a whole number)
Selected Answer: 10
5
Correct Answer:
Evaluation Method Correct Answer
Exact Match 1350
Question 8
1 out of 1 points
The nurse is administering mannitol IV to decrease the patient's ICP following a craniotomy. Which lab test result should the nurse monitor
Selected Answer:
A. Serum osmolarity
Answers:
A. Serum osmolarity
B. White blood cell count
C. Serum cholesterol
D. ESR
Question 9
1 out of 1 points
The nurse is assessing the patient after sustaining a closed head injury. When applying nailbed pressure the patient's body stiffens, the eyes roll upward, and there is increased salivation and a loss of swallowing reflex. Which observation should the nurse document
Selected Answer:
D. T onic seizure activity
Answers:A. Decerebrate posturing
B. Decorticate posturing
C.
