NUR 2025: EXAM 2 PREPARATION
a nurse is caring for a client who was recently admitted to the ED following a head-on motor vehicle
crash. the client is unresponsive, has spontaneous respirations of 22/min, & a laceration on his forehead
that is bleeding. what is the nurses priority at this time? - (correct Answer) - keep the patient's neck
stabilized.
the greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. the
priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled
out.
a nurse is caring for a client who experienced a traumatic brain injury. which of the following findings
indicates the client is experiencing increased intracranial pressure?
a. Battle's sign
b. Periorbital edema
c. Dilated pupils
d. Halo sign - (correct Answer) - c. CORRECT: Dilated pupils can indicate that intracranial pressure is
increasing.
Battle's sign is bruising behind the ear and lower jaw that can occur from the trauma of a skull fracture.
Periorbital edema is a result of facial trauma
halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. the ring
indicates leakage of CSF that can occur with a skull fracture.
RN is assessing a patient with SCI. which of the following findings indicates the client might be
experiencing neurogenic shock?
a. inspiratory crackles
b. heart rate 52/min
c. angioedema
d. temp. 102.6 - (correct Answer) - b. CORRECT. heart rate 52/min
a nurse is assessing a client who has a high-thoracic spinal cord injury. the nurse should identify which of
the following findings as a manifestation of autonomic dysreflexia?
a nurse is caring for a client who was recently admitted to the ED following a head-on motor vehicle
crash. the client is unresponsive, has spontaneous respirations of 22/min, & a laceration on his forehead
that is bleeding. what is the nurses priority at this time? - (correct Answer) - keep the patient's neck
stabilized.
the greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. the
priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled
out.
a nurse is caring for a client who experienced a traumatic brain injury. which of the following findings
indicates the client is experiencing increased intracranial pressure?
a. Battle's sign
b. Periorbital edema
c. Dilated pupils
d. Halo sign - (correct Answer) - c. CORRECT: Dilated pupils can indicate that intracranial pressure is
increasing.
Battle's sign is bruising behind the ear and lower jaw that can occur from the trauma of a skull fracture.
Periorbital edema is a result of facial trauma
halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. the ring
indicates leakage of CSF that can occur with a skull fracture.
RN is assessing a patient with SCI. which of the following findings indicates the client might be
experiencing neurogenic shock?
a. inspiratory crackles
b. heart rate 52/min
c. angioedema
d. temp. 102.6 - (correct Answer) - b. CORRECT. heart rate 52/min
a nurse is assessing a client who has a high-thoracic spinal cord injury. the nurse should identify which of
the following findings as a manifestation of autonomic dysreflexia?
