Nur 265 exam 3 with correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse is working in the emergency department and is
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
admitting a client who has a sustained TBI, following a motor ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
vehicle crash, it is a priority for the nurse to notify the primary ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
health care provider if the client ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
takes prescribed warfarin daily ||\\||\\ ||\\||\\ ||\\||\\
The charge nurse observes a newly hired nurse caring 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 clients bed ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
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 ||\\||\\ ||\\||\\ ||\\||\\
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 yr old college student who participates on the football team
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
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 the TBI
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse is caring for a client with a TBI and a skull fracture.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse noted that the client had ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
developed rhinorrhea (nasal drip) positive for glucose. Which of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the following actions should the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
nurse take next? ||\\||\\ ||\\||\\
Perform a halo sign test ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse is providing discharge instructions to a client's partner
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
who sustained a mild head
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
injury due to an MVA. Which of the following statements, if ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
made by the partners, would indicate ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the need for additional teaching? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
i will bring my partner to the ED if they immediately starting
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
vomiting
The nurse is caring for the following assigned clients. Which
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
client should the nurse see first? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The client who has brain injusry and bp change from 110/58 to
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134/40
The nurse is working in the emergency department and is
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
admitting a client who has a sustained TBI, following a motor ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
vehicle crash, it is a priority for the nurse to notify the primary ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
health care provider if the client ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
takes prescribed warfarin daily ||\\||\\ ||\\||\\ ||\\||\\
The charge nurse observes a newly hired nurse caring 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 clients bed ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
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 ||\\||\\ ||\\||\\ ||\\||\\
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 yr old college student who participates on the football team
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
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 the TBI
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse is caring for a client with a TBI and a skull fracture.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse noted that the client had ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
developed rhinorrhea (nasal drip) positive for glucose. Which of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the following actions should the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
nurse take next? ||\\||\\ ||\\||\\
Perform a halo sign test ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse is providing discharge instructions to a client's partner
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
who sustained a mild head
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
injury due to an MVA. Which of the following statements, if ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
made by the partners, would indicate ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the need for additional teaching? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
i will bring my partner to the ED if they immediately starting
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
vomiting
The nurse is caring for the following assigned clients. Which
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
client should the nurse see first? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The client who has brain injusry and bp change from 110/58 to
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
134/40
