NUR 265 exam 3 Questions with 100% Correct
Answers
RN working in ED and is admitting a pt who has TBI from
MVC-- what is the priority to notify to PCP— Correct
Answer: takes warfarin daily--there could be a
hemorrhage as part of the injury. warfarin is a blood
thinner
Newly hired nurse caring for a pt who has a closed head
injury, on a vent, at risk for ICP--what action requires
intervention?— Correct Answer: raising the foot of the pt
beds-- maintain the head midline/neutral position to
prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--
what requires intervention ?— Correct Answer: clustering
pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the
following pts should the nurse identity as the greatest
risk?— Correct Answer: 20 year old college student who
is on the football team.
, Nurse w assigned pts. which assessment finding would
need to be reported to PCP?— Correct Answer: the
development of asymmetric pupils with no reaction to
light in the pt who has a TBI-- pupillary changes;
nurse caring for a pt who had a TBI w skull fx. the nurse
noted that the pt has rhinorrhea and it is positive for
glucose--what action is next?— Correct Answer: perform
a halo sign test--CSG leaking, lab test will be analyzed
for glucose and electrolyte content. place fluid on a
while absorbent paper/linen
nurse providing dc teaching to pts partner who
sustained a mild head injury from MVC. --what
statement requires additional teaching?— Correct
Answer: I will bring my partner to the ED if they
immediately start vomiting--symptoms usually resolve
within 72 hrs NV is expected.
Nurse is caring for the following pt. which pt would the
nurse see first?— Correct Answer: the pt who has a brain
injury and a BP change from 110/58 to 134/40-- cushings
triad. severe htn, widening pulse pressure, bradycardia
Answers
RN working in ED and is admitting a pt who has TBI from
MVC-- what is the priority to notify to PCP— Correct
Answer: takes warfarin daily--there could be a
hemorrhage as part of the injury. warfarin is a blood
thinner
Newly hired nurse caring for a pt who has a closed head
injury, on a vent, at risk for ICP--what action requires
intervention?— Correct Answer: raising the foot of the pt
beds-- maintain the head midline/neutral position to
prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--
what requires intervention ?— Correct Answer: clustering
pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the
following pts should the nurse identity as the greatest
risk?— Correct Answer: 20 year old college student who
is on the football team.
, Nurse w assigned pts. which assessment finding would
need to be reported to PCP?— Correct Answer: the
development of asymmetric pupils with no reaction to
light in the pt who has a TBI-- pupillary changes;
nurse caring for a pt who had a TBI w skull fx. the nurse
noted that the pt has rhinorrhea and it is positive for
glucose--what action is next?— Correct Answer: perform
a halo sign test--CSG leaking, lab test will be analyzed
for glucose and electrolyte content. place fluid on a
while absorbent paper/linen
nurse providing dc teaching to pts partner who
sustained a mild head injury from MVC. --what
statement requires additional teaching?— Correct
Answer: I will bring my partner to the ED if they
immediately start vomiting--symptoms usually resolve
within 72 hrs NV is expected.
Nurse is caring for the following pt. which pt would the
nurse see first?— Correct Answer: the pt who has a brain
injury and a BP change from 110/58 to 134/40-- cushings
triad. severe htn, widening pulse pressure, bradycardia
