EXAM 2 NURSING 3 COMPREHENSIVE
QUESTIONS AND CORRECT ANSWERS
<VERIFIED ANSWERS> |LATEST UPLOAD
|ALREADY GRADED A+
A patient with a closed head injury has been admitted to the unit. Which vital sign
assessment would be most indicative of increased intracranial pressure (ICP)?
A. BP 120/80, pulse 120, respirations 20
B. BP 180/98, pulse 50, temperature 102° F
C. BP 98/60, pulse 132, temperature 97.6° F
D. BP 170/90, pulse 80, respirations 24 - ANSWER - B. BP 180/98, pulse 50,
temperature 102° F
Vital signs correlating with increased ICP are elevated blood pressure (BP) with
widening pulse pressure; bradycardia; elevated temperature if the hypothalamus
is involved.
The nurse is caring for a patient with a head injury who has an ICP monitor in
place. Assessment reveals an ICP reading of 66. What is the best nursing action?
A. Notify the physician.
B. Document the reading.
C. Turn the patient and recheck the reading.
D. Place the patient in a supine position. - ANSWER - A. Correct Notify the
physician
,Normal ICP is 10 to 15 mm Hg; 66 is an extremely high reading. The physician
should be notified.
A patient with a T6 injury 6 months ago develops facial flushing and a BP of
210/106 mm Hg. After elevating the head of the bed, which is the most
appropriate nursing action?
A. Notify the physician.
B. Assess the patient for a distended bladder.
C. Administer oxygen at 3 L/min.
D. Increase the IV fluids. - ANSWER - B. Correct Assess the patient for a distended
bladder.
The patient appears to be experiencing autonomic hyperreflexia (dysreflexia),
which can be caused by a full or distended bowel or bladder. Assessment of the
abdomen should be accomplished first. There is no indication from the
information provided that oxygen is necessary or would be helpful in this
situation. Increasing IV fluids may increase the patient's BP and further aggravate
the situation.
Which assessment finding would be most indicative of increased ICP in a patient
admitted with a basilar skull fracture?
A. Vomiting
B. Headache
C. Dizziness
, D. Papilledema - ANSWER - D. Correct Papilledema
Papilledema is a hallmark sign of increased ICP.
A patient recovering from a closed head injury is receiving nasogastric (NG) tube
feedings and ant seizure medication, which is supplied in tablet form. Before
administering the medication, what should the nurse do?
A. Crush the medication and combine it with a small amount of ice cream.
B. Assist the patient to sit upright so he can swallow the medication.
C. Crush the tablet, mix in 100 mL of tube feeding, and administer it via the NG
tube.
D. Ask the pharmacist if the medication is available in liquid form and administer
via the NG tube. - ANSWER - D. Correct Ask the pharmacist if the medication is
available in liquid form and administer via the NG tube.
This is the best nursing action in this situation. A patient with a closed head injury
should be elevated no higher than 20 to 30 degrees.
The nurse is at a group picnic when called to help an 18-year-old who fell from a
ledge while he was rock climbing. He now says he can't move his legs. The nurse's
most appropriate action would be to:
A. turn him on his side.
B. instruct him to bend his knees to relieve the pain.
C. keep him still and have someone call for help.
QUESTIONS AND CORRECT ANSWERS
<VERIFIED ANSWERS> |LATEST UPLOAD
|ALREADY GRADED A+
A patient with a closed head injury has been admitted to the unit. Which vital sign
assessment would be most indicative of increased intracranial pressure (ICP)?
A. BP 120/80, pulse 120, respirations 20
B. BP 180/98, pulse 50, temperature 102° F
C. BP 98/60, pulse 132, temperature 97.6° F
D. BP 170/90, pulse 80, respirations 24 - ANSWER - B. BP 180/98, pulse 50,
temperature 102° F
Vital signs correlating with increased ICP are elevated blood pressure (BP) with
widening pulse pressure; bradycardia; elevated temperature if the hypothalamus
is involved.
The nurse is caring for a patient with a head injury who has an ICP monitor in
place. Assessment reveals an ICP reading of 66. What is the best nursing action?
A. Notify the physician.
B. Document the reading.
C. Turn the patient and recheck the reading.
D. Place the patient in a supine position. - ANSWER - A. Correct Notify the
physician
,Normal ICP is 10 to 15 mm Hg; 66 is an extremely high reading. The physician
should be notified.
A patient with a T6 injury 6 months ago develops facial flushing and a BP of
210/106 mm Hg. After elevating the head of the bed, which is the most
appropriate nursing action?
A. Notify the physician.
B. Assess the patient for a distended bladder.
C. Administer oxygen at 3 L/min.
D. Increase the IV fluids. - ANSWER - B. Correct Assess the patient for a distended
bladder.
The patient appears to be experiencing autonomic hyperreflexia (dysreflexia),
which can be caused by a full or distended bowel or bladder. Assessment of the
abdomen should be accomplished first. There is no indication from the
information provided that oxygen is necessary or would be helpful in this
situation. Increasing IV fluids may increase the patient's BP and further aggravate
the situation.
Which assessment finding would be most indicative of increased ICP in a patient
admitted with a basilar skull fracture?
A. Vomiting
B. Headache
C. Dizziness
, D. Papilledema - ANSWER - D. Correct Papilledema
Papilledema is a hallmark sign of increased ICP.
A patient recovering from a closed head injury is receiving nasogastric (NG) tube
feedings and ant seizure medication, which is supplied in tablet form. Before
administering the medication, what should the nurse do?
A. Crush the medication and combine it with a small amount of ice cream.
B. Assist the patient to sit upright so he can swallow the medication.
C. Crush the tablet, mix in 100 mL of tube feeding, and administer it via the NG
tube.
D. Ask the pharmacist if the medication is available in liquid form and administer
via the NG tube. - ANSWER - D. Correct Ask the pharmacist if the medication is
available in liquid form and administer via the NG tube.
This is the best nursing action in this situation. A patient with a closed head injury
should be elevated no higher than 20 to 30 degrees.
The nurse is at a group picnic when called to help an 18-year-old who fell from a
ledge while he was rock climbing. He now says he can't move his legs. The nurse's
most appropriate action would be to:
A. turn him on his side.
B. instruct him to bend his knees to relieve the pain.
C. keep him still and have someone call for help.
