NUR 390 - Exam 3
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1. A 40-yr-old woman who is obese reports that she a. "What factors led to
wants to lose weight. Which question would the nurse your weight gain?"
ask first?
a. "What factors led to your weight gain?"
b. "Which types of food do you like best?"
c. "How long have you been overweight?"
d. "What physical activities do you enjoy?"
2. Which statement by a patient who is being discharged b. "I am going to dri-
from the emergency department (ED) after a concus- ve home and go right to
sion indicates a need for intervention by the nurse? bed."
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go right to bed."
c. "I do not even remember being in an accident to-
day."
d. "I can take acetaminophen (Tylenol) for my
headache."
3. Family members of a patient who has a traumatic b. "The system measures
brain injury ask the nurse about the purpose of the pressures to determine
ventriculostomy system being used for intracranial whether blood flow to the
pressure monitoring. Which statement by the nurse brain is adequate"
would be the best initial response for this situation?
a. "This is a complex type of monitoring system, and
it is managed by skilled staff."
b. "The system measures pressures to determine
whether blood flow to the brain is adequate"
c. "The ventriculostomy monitoring system helps
check for changes in cerebral perfusion pressure."
, NUR 390 - Exam 3
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d. "This monitoring system has many benefits, includ-
ing the ability to drain cerebrospinal fluid."
4. Admission vital signs for a patient who has a brain a. Blood pressure 154/68
injury are blood pressure of 128/68 mm Hg, pulse mm Hg, pulse 56
of 10 beats/min, and of respirations 26 breaths/min. beats/min, respirations 12
Which set of vital signs, if taken 1 hour later, will be of breaths/min
most concern to the nurse?
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min,
respirations 12 breaths/min
b. Blood pressure 134/72 mm Hg, pulse 90 beats/min,
respirations 32 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 12 beats/min,
respirations 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120
beats/min, respirations 30 breaths/min
5. When a brain-injured patient responds to nail bed c. Decorticate posturing
pressure with internal rotation, adduction, and flex-
ion of the arms, how would the nurse report the re-
sponse?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
6. The nurse has administered prescribed IV mannitol c. Intracranial pressure
(Osmitrol) to an unconscious patient. Which parame-
ter would the nurse monitor to determine the med-
ication's effectiveness?
, NUR 390 - Exam 3
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a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
7. A patient with a head injury opens his eyes to verbal b. 11
stimulation, curses when stimulated, and does not
respond to a verbal command to move but attempts
to push away a painful stimulus. How would the nurse
record the patient's Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
8. An unconscious patient is admitted to the emergency c. Allow the family to stay
department (ED) with a head injury. The patient's with the patient and briefly
spouse and teenage children stay at the patient's side explain all procedures to
and ask many questions about the treatment. Which them.
action is best for the nurse to take?
a. Call the family's pastor or spiritual advisor ot take
them to the chapel.
b. Ask the family to stay in the waiting room until the
assessment is completed.
c. Allow the family to stay with the patient and briefly
explain all procedures to them.
d. Refer the family members to the hospital counsel-
ing service to deal with their
anxiety.
9.
, NUR 390 - Exam 3
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A patient who is unconscious after a head injury has c. Keep the head of the
cerebral edema. Which nursing intervention will be bed elevated to 30 de-
included in the plan of care? grees.
a. Encourage coughing and deep breathing
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest peri-
ods.
10. A 20-yr-old is admitted with a head injury after a col- b. Check the drainage for
lision while playing sports. After noting that the pa- glucose content.
tient has developed clear nasal drainage, which action
would the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorthea is expected after
a head injury.
d. Obtain a specimen of the fluid to send for culture
and sensitivity.
11. Which action will the emergency department nurse b. Provide discharge in-
anticipate for a patient diagnosed with a concussion structions about monitor-
who did not lose consciousness? ing neurologic status.
a. Coordinate the transfer of the patient to the oper-
ating room.
b. Provide discharge instructions about monitoring
neurologic status.
c. Arrange to admit the patient to the neurologic unit
for observation.
Study online at https://quizlet.com/_g1whfo
1. A 40-yr-old woman who is obese reports that she a. "What factors led to
wants to lose weight. Which question would the nurse your weight gain?"
ask first?
a. "What factors led to your weight gain?"
b. "Which types of food do you like best?"
c. "How long have you been overweight?"
d. "What physical activities do you enjoy?"
2. Which statement by a patient who is being discharged b. "I am going to dri-
from the emergency department (ED) after a concus- ve home and go right to
sion indicates a need for intervention by the nurse? bed."
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go right to bed."
c. "I do not even remember being in an accident to-
day."
d. "I can take acetaminophen (Tylenol) for my
headache."
3. Family members of a patient who has a traumatic b. "The system measures
brain injury ask the nurse about the purpose of the pressures to determine
ventriculostomy system being used for intracranial whether blood flow to the
pressure monitoring. Which statement by the nurse brain is adequate"
would be the best initial response for this situation?
a. "This is a complex type of monitoring system, and
it is managed by skilled staff."
b. "The system measures pressures to determine
whether blood flow to the brain is adequate"
c. "The ventriculostomy monitoring system helps
check for changes in cerebral perfusion pressure."
, NUR 390 - Exam 3
Study online at https://quizlet.com/_g1whfo
d. "This monitoring system has many benefits, includ-
ing the ability to drain cerebrospinal fluid."
4. Admission vital signs for a patient who has a brain a. Blood pressure 154/68
injury are blood pressure of 128/68 mm Hg, pulse mm Hg, pulse 56
of 10 beats/min, and of respirations 26 breaths/min. beats/min, respirations 12
Which set of vital signs, if taken 1 hour later, will be of breaths/min
most concern to the nurse?
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min,
respirations 12 breaths/min
b. Blood pressure 134/72 mm Hg, pulse 90 beats/min,
respirations 32 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 12 beats/min,
respirations 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120
beats/min, respirations 30 breaths/min
5. When a brain-injured patient responds to nail bed c. Decorticate posturing
pressure with internal rotation, adduction, and flex-
ion of the arms, how would the nurse report the re-
sponse?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
6. The nurse has administered prescribed IV mannitol c. Intracranial pressure
(Osmitrol) to an unconscious patient. Which parame-
ter would the nurse monitor to determine the med-
ication's effectiveness?
, NUR 390 - Exam 3
Study online at https://quizlet.com/_g1whfo
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
7. A patient with a head injury opens his eyes to verbal b. 11
stimulation, curses when stimulated, and does not
respond to a verbal command to move but attempts
to push away a painful stimulus. How would the nurse
record the patient's Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
8. An unconscious patient is admitted to the emergency c. Allow the family to stay
department (ED) with a head injury. The patient's with the patient and briefly
spouse and teenage children stay at the patient's side explain all procedures to
and ask many questions about the treatment. Which them.
action is best for the nurse to take?
a. Call the family's pastor or spiritual advisor ot take
them to the chapel.
b. Ask the family to stay in the waiting room until the
assessment is completed.
c. Allow the family to stay with the patient and briefly
explain all procedures to them.
d. Refer the family members to the hospital counsel-
ing service to deal with their
anxiety.
9.
, NUR 390 - Exam 3
Study online at https://quizlet.com/_g1whfo
A patient who is unconscious after a head injury has c. Keep the head of the
cerebral edema. Which nursing intervention will be bed elevated to 30 de-
included in the plan of care? grees.
a. Encourage coughing and deep breathing
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest peri-
ods.
10. A 20-yr-old is admitted with a head injury after a col- b. Check the drainage for
lision while playing sports. After noting that the pa- glucose content.
tient has developed clear nasal drainage, which action
would the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorthea is expected after
a head injury.
d. Obtain a specimen of the fluid to send for culture
and sensitivity.
11. Which action will the emergency department nurse b. Provide discharge in-
anticipate for a patient diagnosed with a concussion structions about monitor-
who did not lose consciousness? ing neurologic status.
a. Coordinate the transfer of the patient to the oper-
ating room.
b. Provide discharge instructions about monitoring
neurologic status.
c. Arrange to admit the patient to the neurologic unit
for observation.
