Hesi level 3 Test Questions with 100%
Correct Answers Graded A+
describe the Glasgow Coma Scale. - ✔✔ LOC assessment based on a score of 3-
15, with scores less than 7 indicative of coma
List four nursing diagnosis for the comatose client in order of priority (remember Maslow's hierarchy of needs to help determine priorities) - ✔✔ Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output
State 4 independent nursing interventions to maintain adequate respiration, airway,
and oxygenation in the unconscious client - ✔✔ Position for maximum ventilation prone or semi prone and slightly to one side.
insert airway if tongue is obstructing.
suction airway efficiently monitor arterial P02 and PC02 and hyperventilate with 100% O2 before sectioning
Who is at risk for stroke - ✔✔ Persons with history of hypertension, previous TIAs, cardiac disease (atrial flutter or fibrillation), diabetes, or oral contraceptive use, and older adults
Complications of immobility include the potential for thrombus development state three nursing interventions to prevent thrombi - ✔✔ Frequent range of motion exercises, frequent (every two hours) position changes, and avoidance of positions that decreased venous return.
List four rationales for the appearance of restlessness in an unconscious client. - ✔✔ Anoxia, distended bladder, covert bleeding, or a return to consciousness.
What nursing interventions prevent Corneal drying in a comatose client. - ✔✔ Irrigation of the eyes PRN with sterile prescribe solution, application of opthalmic ointment every eight hours, close assessment for corneal ulceration or drying.
When can a comatose client on IV hyperalimentation begin to receive tube feedings instead - ✔✔ When peristalsis resumes as evidence by active bowel sounds, passage of flatus or bowel movement What is the most important principle in a bowel management program for a client with neurological defects? - ✔✔ Establishment of regularity
Define stroke - ✔✔ A disruption of blood supply to a part of the brain, which results in sudden loss of brain function
A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client suffered a lesion? - ✔✔ Left hemisphere
What are the symptoms of spinal shock? - ✔✔ Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion.
What are the symptoms of autonomic dysreflexia? - ✔✔ Hypertension, bladder and bowel distention, exaggerated autonomic response, headache, sweating, goosebumps, and bradycardia.
What is the most important indicator of increased ICP? - ✔✔ A change in the level of responsiveness
What vital sign Changes are indicated of increase ICP - ✔✔ Increase Blood pressure, widening pulse pressure, increased or decreased pulse, respiratory irregularities, and temperature increase.
A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by his very hyperactive dog. He was wondering what symptoms would indicate the need to visit an emergency department. What should the nurse tell him to do? - ✔✔ Call his physician now and inform him or her of the fall. Symptoms needing medical attention would include vertigo, confusion or any Subtle behavioral changes, headache, vomiting, ataxia (imbalance), or seizure.
What activities and situations that increased ICP should be avoided - ✔✔ Change
in bed position, extreme hip flexion, endotracheal suction, compression of jugular veins, coughing, vomiting, and straining of any kind.
What is the action of hyper osmotic agents (osmotic diuretics) used to treat ICP - ✔✔ They dehydrate the brain and reduce cerebral edema by holding the water in the renal tubule's to prevent reabsorption and by drawing fluid from the extravascular spaces into the plasma
Correct Answers Graded A+
describe the Glasgow Coma Scale. - ✔✔ LOC assessment based on a score of 3-
15, with scores less than 7 indicative of coma
List four nursing diagnosis for the comatose client in order of priority (remember Maslow's hierarchy of needs to help determine priorities) - ✔✔ Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output
State 4 independent nursing interventions to maintain adequate respiration, airway,
and oxygenation in the unconscious client - ✔✔ Position for maximum ventilation prone or semi prone and slightly to one side.
insert airway if tongue is obstructing.
suction airway efficiently monitor arterial P02 and PC02 and hyperventilate with 100% O2 before sectioning
Who is at risk for stroke - ✔✔ Persons with history of hypertension, previous TIAs, cardiac disease (atrial flutter or fibrillation), diabetes, or oral contraceptive use, and older adults
Complications of immobility include the potential for thrombus development state three nursing interventions to prevent thrombi - ✔✔ Frequent range of motion exercises, frequent (every two hours) position changes, and avoidance of positions that decreased venous return.
List four rationales for the appearance of restlessness in an unconscious client. - ✔✔ Anoxia, distended bladder, covert bleeding, or a return to consciousness.
What nursing interventions prevent Corneal drying in a comatose client. - ✔✔ Irrigation of the eyes PRN with sterile prescribe solution, application of opthalmic ointment every eight hours, close assessment for corneal ulceration or drying.
When can a comatose client on IV hyperalimentation begin to receive tube feedings instead - ✔✔ When peristalsis resumes as evidence by active bowel sounds, passage of flatus or bowel movement What is the most important principle in a bowel management program for a client with neurological defects? - ✔✔ Establishment of regularity
Define stroke - ✔✔ A disruption of blood supply to a part of the brain, which results in sudden loss of brain function
A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client suffered a lesion? - ✔✔ Left hemisphere
What are the symptoms of spinal shock? - ✔✔ Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion.
What are the symptoms of autonomic dysreflexia? - ✔✔ Hypertension, bladder and bowel distention, exaggerated autonomic response, headache, sweating, goosebumps, and bradycardia.
What is the most important indicator of increased ICP? - ✔✔ A change in the level of responsiveness
What vital sign Changes are indicated of increase ICP - ✔✔ Increase Blood pressure, widening pulse pressure, increased or decreased pulse, respiratory irregularities, and temperature increase.
A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by his very hyperactive dog. He was wondering what symptoms would indicate the need to visit an emergency department. What should the nurse tell him to do? - ✔✔ Call his physician now and inform him or her of the fall. Symptoms needing medical attention would include vertigo, confusion or any Subtle behavioral changes, headache, vomiting, ataxia (imbalance), or seizure.
What activities and situations that increased ICP should be avoided - ✔✔ Change
in bed position, extreme hip flexion, endotracheal suction, compression of jugular veins, coughing, vomiting, and straining of any kind.
What is the action of hyper osmotic agents (osmotic diuretics) used to treat ICP - ✔✔ They dehydrate the brain and reduce cerebral edema by holding the water in the renal tubule's to prevent reabsorption and by drawing fluid from the extravascular spaces into the plasma
