Capstone exam 3 questions and
answers graded A+ latest update
Diminished breath sounds - correct answer ✔✔The emergency department nurse is assessing a
client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of
a pneumothorax in this client?
Tracheal deviation, Sensation of air hunger, Cyanosis of oral mucous membranes - correct
answer ✔✔Thoracentesis causing pneumothorax (Signs and symptoms of pneumothorax)
Liver function tests. - correct answer ✔✔Zafirlukast is prescribed for a client with bronchial
asthma. Which laboratory test does the nurse expect to be prescribed before the administration
of this medication
I feel like my heart is racing. - correct answer ✔✔The nurse is caring for a client receiving an
albuterol/ipratropium nebulized breathing treatment. Which report from the client should the
nurse note as an expected side effect of this combination
Nail Bed pressure - correct answer ✔✔The nurse is assessing the motor and sensory function of
an unconscious client who sustained a head injury. The nurse should use which technique to
test the client's peripheral response to pain?
headache and vomiting - correct answer ✔✔A nurse is teaching family members of a client with
a concussion about the early signs of increased cranial pressure ICP. Which of the following
would the nurse cite as early signs of ICP?
Vomiting - correct answer ✔✔The nurse is monitoring a 3-year-old child for signs and symptoms
of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which
early sign or symptom of increased ICP?
, decreased level of consciousness (LOC) - correct answer ✔✔What is one of the earliest signs of
increased intracranial pressure ICP?
Bradycardia - correct answer ✔✔A mother arrives at the emergency department with her 5-
year-old chills and states that the child fell off a bunk bed. A head injury is suspected. The nurse
checks the child's airway status and assesses the child for early and late signs of ICP.Which is the
late sign?
Rigid extension and pronation of the arms and legs - correct answer ✔✔The nurse is reviewing
the record of a child with ICP and notes that the child has exhibited signs of decerebrate
posturing. On assessment of the child the nurse expects to note which characteristic of this type
posturing?
Exhaling during repositioning - correct answer ✔✔A client recovering from a head injury is
participating in care. The nurse determines that the client understands measures to prevent
elevations in ICP if the nurse observes the client doing which activity?
Increasing temp, decreasing pulse, decreasing respirations, increasing blood pressure - correct
answer ✔✔The nurse is caring for the client with ICP as a result of a head injury/ the nurse
would note which trend in VS if the intracranial pressure is rising?
Continuing to observe the seizure - correct answer ✔✔A child becomes cyanotic during a
generalized tonic-clonic seizure. What is the most appropriate action by the nurse?
Time the seizure, Stay with the child, Move the furniture away from the child - correct answer
✔✔The nurse is creating a plan of care for a child who is at risk for seizures. Which
interventions apply if the child has a seizure?
Loosening restrictive clothing, Removing the pillow and raising padded side rails, Positioning the
client to the side, if possible with the head flexed forward - correct answer ✔✔The nurse is
answers graded A+ latest update
Diminished breath sounds - correct answer ✔✔The emergency department nurse is assessing a
client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of
a pneumothorax in this client?
Tracheal deviation, Sensation of air hunger, Cyanosis of oral mucous membranes - correct
answer ✔✔Thoracentesis causing pneumothorax (Signs and symptoms of pneumothorax)
Liver function tests. - correct answer ✔✔Zafirlukast is prescribed for a client with bronchial
asthma. Which laboratory test does the nurse expect to be prescribed before the administration
of this medication
I feel like my heart is racing. - correct answer ✔✔The nurse is caring for a client receiving an
albuterol/ipratropium nebulized breathing treatment. Which report from the client should the
nurse note as an expected side effect of this combination
Nail Bed pressure - correct answer ✔✔The nurse is assessing the motor and sensory function of
an unconscious client who sustained a head injury. The nurse should use which technique to
test the client's peripheral response to pain?
headache and vomiting - correct answer ✔✔A nurse is teaching family members of a client with
a concussion about the early signs of increased cranial pressure ICP. Which of the following
would the nurse cite as early signs of ICP?
Vomiting - correct answer ✔✔The nurse is monitoring a 3-year-old child for signs and symptoms
of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which
early sign or symptom of increased ICP?
, decreased level of consciousness (LOC) - correct answer ✔✔What is one of the earliest signs of
increased intracranial pressure ICP?
Bradycardia - correct answer ✔✔A mother arrives at the emergency department with her 5-
year-old chills and states that the child fell off a bunk bed. A head injury is suspected. The nurse
checks the child's airway status and assesses the child for early and late signs of ICP.Which is the
late sign?
Rigid extension and pronation of the arms and legs - correct answer ✔✔The nurse is reviewing
the record of a child with ICP and notes that the child has exhibited signs of decerebrate
posturing. On assessment of the child the nurse expects to note which characteristic of this type
posturing?
Exhaling during repositioning - correct answer ✔✔A client recovering from a head injury is
participating in care. The nurse determines that the client understands measures to prevent
elevations in ICP if the nurse observes the client doing which activity?
Increasing temp, decreasing pulse, decreasing respirations, increasing blood pressure - correct
answer ✔✔The nurse is caring for the client with ICP as a result of a head injury/ the nurse
would note which trend in VS if the intracranial pressure is rising?
Continuing to observe the seizure - correct answer ✔✔A child becomes cyanotic during a
generalized tonic-clonic seizure. What is the most appropriate action by the nurse?
Time the seizure, Stay with the child, Move the furniture away from the child - correct answer
✔✔The nurse is creating a plan of care for a child who is at risk for seizures. Which
interventions apply if the child has a seizure?
Loosening restrictive clothing, Removing the pillow and raising padded side rails, Positioning the
client to the side, if possible with the head flexed forward - correct answer ✔✔The nurse is
