Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
The nurse is working in the emergency
department and is admitting a client who
has a sustained TBI, following a motor
takes prescribed warfarin daily
vehicle crash, it is a priority for the nurse
to notify the primary health care provider
if the client
The charge nurse observes a newly
hired nurse caring for a client who sus-
tained a closed head
injury, is receiving mechanical ventila-
tion, and is at risk for developing ICP. raising the foot of the clients bed
Which of the following
actions, if performed by the newly
hired nurse, requires intervention by the
charge nurse?
The newly hired nurse is caring for a
client who was admitted 12 hours ago
with a TBI and is at risk
Clustering client care activities
for developing ICP. It requires interven-
tion by the nurse preceptor if the newly
hired nurse is observed
The nurse is assessing clients for the risk
of sustaining TBI. Which of the following
20 yr old college student who partici-
clients should
pates on the football team
the nurse identify as being at greatest
risk?
The nurse is caring for assigned clients.
the development of asymmetric pupils
Which of the following assessment find-
with no reaction to light in the client who
ings requires the
has the TBI
nurse to notify the PHCP?
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) posi- Perform a halo sign test
tive for glucose. Which of the following
actions should the
nurse take next?
1/8
, Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
The nurse is providing discharge instruc-
tions to a client's partner who sustained
a mild head
i will bring my partner to the ED if they
injury due to an MVA. Which of the follow-
immediately starting vomiting
ing statements, if made by the partners,
would indicate
the need for additional teaching?
The nurse is caring for the following as-
The client who has brain injusry and bp
signed clients. Which client should the
change from 110/58 to 134/40
nurse see first?
The nurse is caring for a client who is
24 hours post-op following a craniotomy.
The client is
reporting a headache that is rated as an Perform a neurological test
8 on a scale of 0-10 pain scale. Which
of the following actions should the nurse
take?
The nurse is caring for a client who has
encephalitis. It is priority for the nurse to has a change in BP from 120/78 to
follow up if the 130/60
client
The nurse is caring for a client who has
been admitted with suspected bacterial
meningitis. Which Prepare the client for a lumbar puncture
of the following actions should the nurse
take first?
The nurse is caring for the client who
has confusion, fever, headache, blurred
vision, NV, and a implement seizure precautions
history of HIV. Which of the following ac-
tions should the nurse take first?
Findings: T5 SCI 6 months ago, flushed
face, profuse sweating, reports blurred
palpate the clients bladder (Autonomic
vision, BP 145/95,
dysreflexia)
HR 68, O2 95%. Which of the following
actions should the nurse take?
2/8
Study online at https://quizlet.com/_d8r6jq
The nurse is working in the emergency
department and is admitting a client who
has a sustained TBI, following a motor
takes prescribed warfarin daily
vehicle crash, it is a priority for the nurse
to notify the primary health care provider
if the client
The charge nurse observes a newly
hired nurse caring for a client who sus-
tained a closed head
injury, is receiving mechanical ventila-
tion, and is at risk for developing ICP. raising the foot of the clients bed
Which of the following
actions, if performed by the newly
hired nurse, requires intervention by the
charge nurse?
The newly hired nurse is caring for a
client who was admitted 12 hours ago
with a TBI and is at risk
Clustering client care activities
for developing ICP. It requires interven-
tion by the nurse preceptor if the newly
hired nurse is observed
The nurse is assessing clients for the risk
of sustaining TBI. Which of the following
20 yr old college student who partici-
clients should
pates on the football team
the nurse identify as being at greatest
risk?
The nurse is caring for assigned clients.
the development of asymmetric pupils
Which of the following assessment find-
with no reaction to light in the client who
ings requires the
has the TBI
nurse to notify the PHCP?
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) posi- Perform a halo sign test
tive for glucose. Which of the following
actions should the
nurse take next?
1/8
, Nur 265 exam 3
Study online at https://quizlet.com/_d8r6jq
The nurse is providing discharge instruc-
tions to a client's partner who sustained
a mild head
i will bring my partner to the ED if they
injury due to an MVA. Which of the follow-
immediately starting vomiting
ing statements, if made by the partners,
would indicate
the need for additional teaching?
The nurse is caring for the following as-
The client who has brain injusry and bp
signed clients. Which client should the
change from 110/58 to 134/40
nurse see first?
The nurse is caring for a client who is
24 hours post-op following a craniotomy.
The client is
reporting a headache that is rated as an Perform a neurological test
8 on a scale of 0-10 pain scale. Which
of the following actions should the nurse
take?
The nurse is caring for a client who has
encephalitis. It is priority for the nurse to has a change in BP from 120/78 to
follow up if the 130/60
client
The nurse is caring for a client who has
been admitted with suspected bacterial
meningitis. Which Prepare the client for a lumbar puncture
of the following actions should the nurse
take first?
The nurse is caring for the client who
has confusion, fever, headache, blurred
vision, NV, and a implement seizure precautions
history of HIV. Which of the following ac-
tions should the nurse take first?
Findings: T5 SCI 6 months ago, flushed
face, profuse sweating, reports blurred
palpate the clients bladder (Autonomic
vision, BP 145/95,
dysreflexia)
HR 68, O2 95%. Which of the following
actions should the nurse take?
2/8
