Nursing 202 Exam 3 Questions With
Correct Answers
A nurse is caring for a client who has increased ICP and a new
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prescription for mannitol (Osmitrol). For which of the following adverse
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effects should the nurse monitor?
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A.) Hyperglycemia
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B.) Hyponatremia
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C.) Hypervolemia
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D.) Oliguria - CORRECT ANSWER✔✔-B.) Hyponatremia
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A nurse is caring for a client who has a closed-head injury with ICP
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readings ranging from 16-22 mmHg. Which of the following actions
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should the nurse take to decrease the potential for raising the client's
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ICP? (Select all that apply.)
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A.) Suction the endotracheal tube.
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B.) Hyperventilate the client.
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C.) Elevate the client's head on two pillows.
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D.) Administer a stool softener.
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E.) Keep the client well hydrated. - CORRECT ANSWER✔✔-B.)
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Hyperventilate the client (Hyperventilating the client will prevent
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hypercarbia, which can cause vasodilation) | | | |
,D.) Administer a stool softener (Administration of a stool softener will
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decrease the need to bear down (Valsalva maneuver) during bowel
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movements, which can increase ICP.) | | | |
Patient's eyes are open and the patient is speaking to you as you are
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examining them. The patient is speaking normally and answering
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questions appropriately. The patient is able to follow commands like
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"show me two fingers". - CORRECT ANSWER✔✔-GCS - 15
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The patient's eyes remain closed, even if someone calls loudly. However,
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the patient will open eyes if pinched. The patient states "don't" or
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"stop" when pinched, but does not speak in whole sentences and does
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not answer any questions. The patient does not follow any commands,
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but if pinched, will quickly push the nurse's hand away. - CORRECT
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ANSWER✔✔-GCS - 10 | |
The patient has their eyes closed at first, but opens them if their name is
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called loudly. The patient does not say any recognizable words. When
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asked a question, the patient looks confused and says, "mmm?" without
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opening their mouth. The patient does not follow commands, but if
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pinched, they pull away. - CORRECT ANSWER✔✔-GCS - 9
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Patient's eyes remain closed, even when pinched. The patient does not
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make any sounds, even if pinched, and he/she does not follow
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commands. Finally, the patient will not moved, even if pinched. -
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CORRECT ANSWER✔✔-GCS - 3 | | |
,Patient's eyes are open and looking at you while you are examining
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them. Speech is clear, but confused. The patient does not know what
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happened to them and states the wrong month when asked the date.
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The patient is slow to follow commands when asked to show two
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fingers, but is still able to do so. - CORRECT ANSWER✔✔-GCS - 14
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The patient's eyes remain closed, even when pinched. He/she groans in
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response to being pinched, but does not say any recognizable words.
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The patient does not follow any commands, but if pinched will try to
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push the nurse's hand away. - CORRECT ANSWER✔✔-GCS - 8
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The patient's eyes will open and will be looking around with an anxious
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expression on their face. The patient will not answer any questions at
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all. If pinched the patient will groan, but does not say any recognizable
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words. The patient does not follow any commands, but if pinched will
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quickly push the nurse's hand away. - CORRECT ANSWER✔✔-GCS - 11
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The patient's eyes will be closed, but will open briefly if someone calls
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to them loudly. The patient will not answer any questions. If pinched,
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the patient will groan or yell, but does not say any recognizable words.
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The patient does not follow any commands, but if pinched will quickly
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push the nurse's hand away. - CORRECT ANSWER✔✔-GCS - 10
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, The patient's eyes are closed, but will open them if someone speaks to
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them. The patient can speak normally, but is confused. The patient does
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not remember exactly what happened to them, and gives the wrong
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month when asked the date. The patient is slow to follow commands
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such as, "show me two fingers", but they are able to do so. - CORRECT
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ANSWER✔✔-GCS - 13 | |
The patient's eyes are closed even if someone talks to them or pinches
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them. The patient answers questions correctly. The patient states that
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"his head hurts". When asked to open eyes, the patient refuses stating,
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"the light makes my eyes hurt really bad." The patient follows
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commands appropriately, but does not open eyes when doing so. -
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CORRECT ANSWER✔✔-GCS - 12 | | |
A nurse is caring for a client who has just been admitted following
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surgical evacuation of a subdural hematoma. Which of the following is
| | | | | | | | | | |
the priority assessment?
| |
A.) Glasgow Coma Scale
| | |
B.) Cranial nerve function
| | |
C.) Oxygen saturation
| |
D.) Pupillary response - CORRECT ANSWER✔✔-C.) Oxygen saturation
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A nurse is caring for a client who was recently admitted to the
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emergency department following a head-on motor vehicle crash. The
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client is unresponsive, has spontaneous respirations of 22/min, and has
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Correct Answers
A nurse is caring for a client who has increased ICP and a new
| | | | | | | | | | | | | |
prescription for mannitol (Osmitrol). For which of the following adverse
| | | | | | | | | |
effects should the nurse monitor?
| | | |
A.) Hyperglycemia
|
B.) Hyponatremia
|
C.) Hypervolemia
|
D.) Oliguria - CORRECT ANSWER✔✔-B.) Hyponatremia
| | | | |
A nurse is caring for a client who has a closed-head injury with ICP
| | | | | | | | | | | | | |
readings ranging from 16-22 mmHg. Which of the following actions
| | | | | | | | | |
should the nurse take to decrease the potential for raising the client's
| | | | | | | | | | | |
ICP? (Select all that apply.)
| | | |
A.) Suction the endotracheal tube.
| | | |
B.) Hyperventilate the client.
| | |
C.) Elevate the client's head on two pillows.
| | | | | | |
D.) Administer a stool softener.
| | | |
E.) Keep the client well hydrated. - CORRECT ANSWER✔✔-B.)
| | | | | | | | |
Hyperventilate the client (Hyperventilating the client will prevent
| | | | | | | |
hypercarbia, which can cause vasodilation) | | | |
,D.) Administer a stool softener (Administration of a stool softener will
| | | | | | | | | | |
decrease the need to bear down (Valsalva maneuver) during bowel
| | | | | | | | | |
movements, which can increase ICP.) | | | |
Patient's eyes are open and the patient is speaking to you as you are
| | | | | | | | | | | | | |
examining them. The patient is speaking normally and answering
| | | | | | | | |
questions appropriately. The patient is able to follow commands like
| | | | | | | | |
"show me two fingers". - CORRECT ANSWER✔✔-GCS - 15
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The patient's eyes remain closed, even if someone calls loudly. However,
| | | | | | | | | |
the patient will open eyes if pinched. The patient states "don't" or
| | | | | | | | | | | |
"stop" when pinched, but does not speak in whole sentences and does
| | | | | | | | | | | | |
not answer any questions. The patient does not follow any commands,
| | | | | | | | | | |
but if pinched, will quickly push the nurse's hand away. - CORRECT
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ANSWER✔✔-GCS - 10 | |
The patient has their eyes closed at first, but opens them if their name is
| | | | | | | | | | | | | |
called loudly. The patient does not say any recognizable words. When
| | | | | | | | | | | |
asked a question, the patient looks confused and says, "mmm?" without
| | | | | | | | | |
opening their mouth. The patient does not follow commands, but if
| | | | | | | | | | | |
pinched, they pull away. - CORRECT ANSWER✔✔-GCS - 9
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Patient's eyes remain closed, even when pinched. The patient does not
| | | | | | | | | | |
make any sounds, even if pinched, and he/she does not follow
| | | | | | | | | | |
commands. Finally, the patient will not moved, even if pinched. -
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CORRECT ANSWER✔✔-GCS - 3 | | |
,Patient's eyes are open and looking at you while you are examining
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them. Speech is clear, but confused. The patient does not know what
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happened to them and states the wrong month when asked the date.
| | | | | | | | | | | |
The patient is slow to follow commands when asked to show two
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fingers, but is still able to do so. - CORRECT ANSWER✔✔-GCS - 14
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The patient's eyes remain closed, even when pinched. He/she groans in
| | | | | | | | | | |
response to being pinched, but does not say any recognizable words.
| | | | | | | | | | |
The patient does not follow any commands, but if pinched will try to
| | | | | | | | | | | | |
push the nurse's hand away. - CORRECT ANSWER✔✔-GCS - 8
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The patient's eyes will open and will be looking around with an anxious
| | | | | | | | | | | | |
expression on their face. The patient will not answer any questions at
| | | | | | | | | | | |
all. If pinched the patient will groan, but does not say any recognizable
| | | | | | | | | | | | |
words. The patient does not follow any commands, but if pinched will
| | | | | | | | | | | |
quickly push the nurse's hand away. - CORRECT ANSWER✔✔-GCS - 11
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The patient's eyes will be closed, but will open briefly if someone calls
| | | | | | | | | | | | |
to them loudly. The patient will not answer any questions. If pinched,
| | | | | | | | | | | |
the patient will groan or yell, but does not say any recognizable words.
| | | | | | | | | | | | |
The patient does not follow any commands, but if pinched will quickly
| | | | | | | | | | | |
push the nurse's hand away. - CORRECT ANSWER✔✔-GCS - 10
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, The patient's eyes are closed, but will open them if someone speaks to
| | | | | | | | | | | | |
them. The patient can speak normally, but is confused. The patient does
| | | | | | | | | | |
not remember exactly what happened to them, and gives the wrong
| | | | | | | | | | | |
month when asked the date. The patient is slow to follow commands
| | | | | | | | | | | |
such as, "show me two fingers", but they are able to do so. - CORRECT
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ANSWER✔✔-GCS - 13 | |
The patient's eyes are closed even if someone talks to them or pinches
| | | | | | | | | | | | |
them. The patient answers questions correctly. The patient states that
| | | | | | | | |
"his head hurts". When asked to open eyes, the patient refuses stating,
| | | | | | | | | | | |
"the light makes my eyes hurt really bad." The patient follows
| | | | | | | | | | | |
commands appropriately, but does not open eyes when doing so. -
| | | | | | | | | | |
CORRECT ANSWER✔✔-GCS - 12 | | |
A nurse is caring for a client who has just been admitted following
| | | | | | | | | | | | |
surgical evacuation of a subdural hematoma. Which of the following is
| | | | | | | | | | |
the priority assessment?
| |
A.) Glasgow Coma Scale
| | |
B.) Cranial nerve function
| | |
C.) Oxygen saturation
| |
D.) Pupillary response - CORRECT ANSWER✔✔-C.) Oxygen saturation
| | | | | | |
A nurse is caring for a client who was recently admitted to the
| | | | | | | | | | | | |
emergency department following a head-on motor vehicle crash. The
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client is unresponsive, has spontaneous respirations of 22/min, and has
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