Nursing 130 Exam 2|| CORRECT QUESTIONS|| VERIFIED 100%
What is the most important nursing task to reduce pressure points on a pt? -
ANSWER Rotate pt every 2 hours
What is the Braden scale used for? - ANSWER assess pressure ulcer risk
Which measurements are in the Braden scale? - ANSWER - Sensory perception (1-
4 pts)
- Moisture (1-4 pts)
- Activity (1-4 pts)
- Mobility (1-4 pts)
- Nutrition (1-4 pts)
- Friction & Shear (1-3 pts_
(total of 23 points. The lower the points the bigger the risk for pressure ulcer)
Which conditions does a brain scan pick up? - ANSWER - vascular lesions
- neoplasms
- abscesses
- areas of cerebrovascular ischemia
What does a neuro chair do? - ANSWER help to transfer pt's in and out of bed and
serve as a comfortable place for the pt to rest when out of bed.
, If a pt. with autonomic dysreflexia gets sudden hypertension, they are at risk
for______? - ANSWER Death.
What can a brain abscess lead to? - ANSWER Meningitis
What are the 2 signs for meningeal irritation? - ANSWER - Brudzinski (stiff neck)
- Kernig (stiffness of hamstrings)
How do you test for Brudzinski (stiff neck)? - ANSWER Severe neck stiffness causes
a patient's hips and knees to flex when the neck is flexed
How do you test for Kernig (stiffness of hamstrings)? - ANSWER inability to
straighten the leg when the hip is flexed to 90 degrees.
What should a nurse never do to a pt with increased intracranial pressure? -
ANSWER never move the head up or down without specific orders from
healthcare provider.
Which part of the brain is involved with long term memory? - ANSWER
Hippocampus
Stimulating the vagus nerve does what? - ANSWER decreased heart rate
why do we dextrostix fluid seeping from eyes, ears, or nose in head injury pt's? -
ANSWER to determine if glucose is present
What is the most important nursing task to reduce pressure points on a pt? -
ANSWER Rotate pt every 2 hours
What is the Braden scale used for? - ANSWER assess pressure ulcer risk
Which measurements are in the Braden scale? - ANSWER - Sensory perception (1-
4 pts)
- Moisture (1-4 pts)
- Activity (1-4 pts)
- Mobility (1-4 pts)
- Nutrition (1-4 pts)
- Friction & Shear (1-3 pts_
(total of 23 points. The lower the points the bigger the risk for pressure ulcer)
Which conditions does a brain scan pick up? - ANSWER - vascular lesions
- neoplasms
- abscesses
- areas of cerebrovascular ischemia
What does a neuro chair do? - ANSWER help to transfer pt's in and out of bed and
serve as a comfortable place for the pt to rest when out of bed.
, If a pt. with autonomic dysreflexia gets sudden hypertension, they are at risk
for______? - ANSWER Death.
What can a brain abscess lead to? - ANSWER Meningitis
What are the 2 signs for meningeal irritation? - ANSWER - Brudzinski (stiff neck)
- Kernig (stiffness of hamstrings)
How do you test for Brudzinski (stiff neck)? - ANSWER Severe neck stiffness causes
a patient's hips and knees to flex when the neck is flexed
How do you test for Kernig (stiffness of hamstrings)? - ANSWER inability to
straighten the leg when the hip is flexed to 90 degrees.
What should a nurse never do to a pt with increased intracranial pressure? -
ANSWER never move the head up or down without specific orders from
healthcare provider.
Which part of the brain is involved with long term memory? - ANSWER
Hippocampus
Stimulating the vagus nerve does what? - ANSWER decreased heart rate
why do we dextrostix fluid seeping from eyes, ears, or nose in head injury pt's? -
ANSWER to determine if glucose is present
