MED SURG 3 EXAM 3.

MED SURG 3 EXAM 3. 1. A nurse should anticipate giving a client with a tempoparol parietal fracture which of the following meds to reduce ICP? Mannitol 2. If a clients paCO2 level rises, what happens to the cerebral blood flow? Dilates 3. An expected outcome of mannitol or furosemide administration in clients with increased ICP is? Increase urine output 4. A client diagnosed with DI has an order to receive vasopressin intranasally. Which of the following assessments indicates to a nurse that the treat is effective? Urinating 3-4 hours 5. A client with a serum sodium of 115 has a decreased LOC and is complaining of a headache. A nurse knows that the client is at risk for cerebral edema caused by? Shif t of fluid into intracellular space 6. A client is admitted to the nuerological ICU following a MVA which resulted in a closed head injury. Which of the following is an appropriate short term goal for this client? Icp shouldn’t increase 15 7. A client is brought to ER immediately after a head trauma that resulted in a fracture to the temporal bone. What clinical manifestation is considered a neurological emergency? Change in LOC 8. The family of a client with a severe head injury states that they do not understand why the client is being put into a drug induced (barbiturate) coma when brain damage may be present. Whats the nurses best response? This med is used to decrease the activity of the brain so more damage doesn’t occur 9. During assessment of a client with a head injury, a nurse notes that the arms, wrists, and fingers are flexed, and the arms are adducted. The nurse notes? Decorticate 10. The nurse is caring for a client postop who had a craniotomy. The nurse is preparing meperidine (Demerol) 100 mg when the client complains of pain of 7. The medication available on the unit is meperidine 20mg/ml. at this time, the nurse should administer? 0.5 mL and another RN to witness the waste 11. Four victims of an automobile accident are brought by ambulance to the ER. The nurse determines that the victim who has the highest priority for treatment is? Sucking chest wound 12. A client with a spinal cord injury at C3-4 is being cared for in the ER. What is the priority assessment? Monitor resp effort and oxygen saturation level 13. The nurse on the rehab unit is caring for the following clients. Which client should the nurse assess first after receiving the change of shift report? C6 spinal cord who is complaining of dyspnea and has crackles in his lungs 14. Bowel and bladder function are impaired after a complete spinal cord injury. Which of the following statements about what occurs immediately after the injury is true? NG tube usually inserted to decompress the stomach 15. A nurse is caring for a client who has had a complete cervical spine injury for many years. The client tells the nurse he has an extreme headache. The nurse assesses a blood pressure of 190/100. Which of the following interventions should be performed first? Look for kinked foley catheter and bowel impaction