Nur 265 Literally Exam 3. (Answered) Complete Solution

Nur 265 Literally Exam 3. (Answered) Complete Solution #1: The nurse is working in the emergency department (ED) is admitting a client who has sustained a traumatic brain injury (TBI) following a motor vehicle crash. It is priority for the nurse to notify the primary healthcare provider (PHCP) in the client: Takes prescribed warfarin daily. RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment of impact. Warfarin is a blood thinner and the patient may bleed out if they have a hematoma (a collection of blood) #2: The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following actions, if performed by the newly hired nurse, requires intervention by the charge nurse? Raising the foot of the client’s bed. RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP. #3: The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed Clustering client care activities RATIONALE: pg. 2387. When multiple activities are clustered in a row, the effect on ICP can be dramatic elevation. #4: The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should the nurse identify as being at greatest risk? 20 year old college student who participates on the football team. RATIONALE: Pg. 2397. A force produce by a blow direct to the head can contribute to a brain injury. #5: The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse to notify the PHCP? The development of asymmetric pupils with no reaction to light in the client who has a TBI. RATIONALE: Pg. 2386. Pupillary changes; dilated and non reactive pupils “blown” or constrictive, non reactive pupils. #6: The nurse is caring for a client who had a TBI with skull fracture. The nurse noted that the client has developed rhinorrhea (nasal drip) that is positive for glucose. Which of the following actions should the nurse take next? Perform a halo sign test. RATIONALE: Pg. 2410. CSF leaking, lab test will be analyzed for glucose and electrolyte content. Place on a white absorbent paper or linen. #7: The nurse is providing discharge instructions to the partner of a client who sustained a mild head injury as a result of a MVA. Which of the following statements, if made by the partners would indicated the need for additional teaching? I will bring my partner to the ED if they immediately starting vomiting. RATIONALE: Pg. 2405. Symptoms usually resolve within 72 hrs. NV expected. #8: The nurse is caring for the following assigned clients. Which client should the nurse see first? The client who has a brain injury and a BP change from 110/58 to 134/40 mm Hg. RATIONALE: Pg. 2386. Cushing Triad. Severe HTN, widened pulse pressure, bradycardia. #9: The nurse is caring for a client who is 24 hours post op following a craniotomy. The client is reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which of the following actions should the nurse take? Perform a neurological test. RATIONALE: Pg. 2430. Symptoms of increased ICP included servers headache, deteriorating LOC, restlessness, and irritability. #10: The nurse is caring for a client who has encephalitis. It is priority for the nurse to follow up if the client Has a change in BP from 120/78 to 130/60 mm Hg. RATIONALE: Pg. 2256. Changes in VS that require immediate notification to the HCP are a widened pulse pressure, new bradycardia, and irregular respiratory effort. #11: The nurse is caring for a client who has been admitted with suspected bacterial meningitis. Which of the following actions should the nurse take first? Prepare the client for a lumbar puncture. RATIONALE: Pg. 2251. Most significant lab test to determine BM is testing of CSF with a lumbar puncture. A broad spectrum antibiotic is given before the lumbar puncture. #12: The nurse is caring for the client who has confusion, fever, headache, blurred vision, NV, and a history of HIV. Which of the following actions should the nurse take first? Implement seizure precautions. RATIONALE: This patient could have encephalitis due to the hx of HIV and fever. Seizure activity is common. #13: Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports blurred vision, BP 145/95, HR 68, O2 95%. Which of the following actions should the nurse take?