NUR 211 QUESTIONS & ANSWERS 2025 A+ GRADED

NUR 211 QUESTIONS & ANSWERS 2025 A+ GRADED 1. A 30-year-old female patient is brought to the emergency department after a motor vehicle accident. She is unconscious with a Glasgow Coma Scale (GCS) score of 6. What is the most appropriate initial nursing intervention? A) Administer intravenous fluids B) Perform a rapid neurological assessment C) Ensure airway patency and provide oxygen D) Obtain a detailed medical history from family members: C- In patients with severe brain injury and a low GCS score, maintaining airway patency and ensuring adequate oxygenation is the top priority to prevent hypoxia and further brain damage. Administering intravenous fluids (A) can be important but is secondary to airway management. Performing a rapid neurological assessment (B) is crucial, but it follows ensuring the airway is secure. Obtaining a detailed medical history (D) is al 2. A client was moved from the ED to the burn unit and is the acute phase of burn management. The client has full-thickness burns to the anterior trunk, perineum, and sacral areas of the body. The nurse is creating a care plan for the client. Which is the most appropriate priority diagnosis at this time? A) Risk for fluid volume overload B) Impaired skin integrity C) Risk for infection D) Impaired physical mobility: C- In the emergent phase, the client's airway is priority and body fluids are replaced. In the acute phase, diuresis, wound healing, and complications are managed, and in the rehabilitative phase, psychosocial support and rehab is provided to get the client back to their optimal functioning. 3. A patient is brought into the ED after a fall causing a traumatic brain injury. The nurse is monitoring for signs on increased intracranial pressure (ICP). What are the signs of increased ICP? Select all that apply.