NUR 265 Exam 3 Questions with 100% Correct
Answers
A patient with a head injury will need follow up if what
occurs? Correct Answer: BP of 166/53
(has a wide MAP and needs follow up... ABC)
What do we need to prevent with cervical neck and
head injuries? Correct Answer: Prevent lumbar and
thoracic fracture (so keep patient midline and straight)
What do we avoid with TBI patients? Correct Answer:
avoid cluster care for TBI patients (reduce stimulus)
What position does a TBI patient need to be in? Correct
Answer: head and neck in midline neutral position
TBI patients require what kind of environment? Correct
Answer: Quiet
Do NOT encourage coughing or deep breathing hourly
as part of the plan of care for a TBI patient Correct
Answer: (this causes increased risk for ICP)
,What is included in the plan of care for a TBI patient?
Correct Answer: -hyperoxygenate
-quiet environment
-avoid cluster care
What is a normal finding in TBI patient? Correct Answer: -
amnesia at time of injury
-GCS score of 14
-photophobia
-balance and gait problems are consistent in TBI
patients
What requires further intervention for a TBI patient (what
is wrong) Correct Answer: -Do NOT encourage deep
breathing or coughing (increases ICP)
-Do NOT do hip ROM exercises (need to be straight and
midline)
-A widened pulse pressure is NOT consistent with TBI
(intervention needed or priority patient)
, -Pupil changes are not expected and are an issue
(brainstem issue)
which pt finding in skull fracture requires immediate MD
notification? Correct Answer: becomes irritable and
restlessness
What Glasgow coma scale is consistent with a TBI
patient? Correct Answer: 14
Which statement does not indicate understanding for
post ip confusion care? Correct Answer: "I will add
stimulation to help me cope"
you should decrease stimulation
Who is at a higher risk for TBI? Correct Answer: 72 year-
old with MS is at greater risk for TBI
A patient with bacterial meningitis who becomes
lethargic is? Correct Answer: Priority patient
Which finding in your meningitis pt requires follow up?
Correct Answer: GCS from 14 to 11
(change in GSC of 2 call RR and doctor)
Answers
A patient with a head injury will need follow up if what
occurs? Correct Answer: BP of 166/53
(has a wide MAP and needs follow up... ABC)
What do we need to prevent with cervical neck and
head injuries? Correct Answer: Prevent lumbar and
thoracic fracture (so keep patient midline and straight)
What do we avoid with TBI patients? Correct Answer:
avoid cluster care for TBI patients (reduce stimulus)
What position does a TBI patient need to be in? Correct
Answer: head and neck in midline neutral position
TBI patients require what kind of environment? Correct
Answer: Quiet
Do NOT encourage coughing or deep breathing hourly
as part of the plan of care for a TBI patient Correct
Answer: (this causes increased risk for ICP)
,What is included in the plan of care for a TBI patient?
Correct Answer: -hyperoxygenate
-quiet environment
-avoid cluster care
What is a normal finding in TBI patient? Correct Answer: -
amnesia at time of injury
-GCS score of 14
-photophobia
-balance and gait problems are consistent in TBI
patients
What requires further intervention for a TBI patient (what
is wrong) Correct Answer: -Do NOT encourage deep
breathing or coughing (increases ICP)
-Do NOT do hip ROM exercises (need to be straight and
midline)
-A widened pulse pressure is NOT consistent with TBI
(intervention needed or priority patient)
, -Pupil changes are not expected and are an issue
(brainstem issue)
which pt finding in skull fracture requires immediate MD
notification? Correct Answer: becomes irritable and
restlessness
What Glasgow coma scale is consistent with a TBI
patient? Correct Answer: 14
Which statement does not indicate understanding for
post ip confusion care? Correct Answer: "I will add
stimulation to help me cope"
you should decrease stimulation
Who is at a higher risk for TBI? Correct Answer: 72 year-
old with MS is at greater risk for TBI
A patient with bacterial meningitis who becomes
lethargic is? Correct Answer: Priority patient
Which finding in your meningitis pt requires follow up?
Correct Answer: GCS from 14 to 11
(change in GSC of 2 call RR and doctor)
