NUR 265 Exam 3 Review Questions And
Answers
RN working in ED and is admitting a pt who has TBI from MVC-- what is
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the priority to notify to PCP - CORRECT ANSWER✔✔-takes warfarin
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daily--there could be a hemorrhage as part of the injury. warfarin is a
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blood thinner |
Newly hired nurse caring for a pt who has a closed head injury, on a
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vent, at risk for ICP--what action requires intervention? - CORRECT
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ANSWER✔✔-raising the foot of the pt beds-- maintain the head | | | | | | | | | |
midline/neutral position to prevent increased ICP | | | | |
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires
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intervention ? - CORRECT ANSWER✔✔-clustering pt care/activities--
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cluster care= increased ICP | | |
assessing pts for the risk of sustaining TBI, which of the following pts
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should the nurse identity as the greatest risk? - CORRECT ANSWER✔✔-
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20 year old college student who is on the football team.
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, Nurse w assigned pts. which assessment finding would need to be
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reported to PCP? - CORRECT ANSWER✔✔-the development of
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asymmetric pupils with no reaction to light in the pt who has a TBI--
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pupillary changes; |
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the
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pt has rhinorrhea and it is positive for glucose--what action is next? -
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CORRECT ANSWER✔✔-perform a halo sign test--CSG leaking, lab test
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will be analyzed for glucose and electrolyte content. place fluid on a
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while absorbent paper/linen
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nurse providing dc teaching to pts partner who sustained a mild head
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injury from MVC. --what statement requires additional teaching? -
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CORRECT ANSWER✔✔-I will bring my partner to the ED if they
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immediately start vomiting--symptoms usually resolve within 72 hrs NV
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is expected.
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Nurse is caring for the following pt. which pt would the nurse see first? -
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CORRECT ANSWER✔✔-the pt who has a brain injury and a BP change
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from 110/58 to 134/40-- cushings triad. severe htn, widening pulse
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pressure, bradycardia |
24 hr post op craniotomy. pt is reporting headach 8/10-- what is the
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next step for the nurse to take? - CORRECT ANSWER✔✔-perform a
| | | | | | | | | | |
neuro assessment--minimize ICP, assess the problem.
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Answers
RN working in ED and is admitting a pt who has TBI from MVC-- what is
| | | | | | | | | | | | | | | |
the priority to notify to PCP - CORRECT ANSWER✔✔-takes warfarin
| | | | | | | | | |
daily--there could be a hemorrhage as part of the injury. warfarin is a
| | | | | | | | | | | | |
blood thinner |
Newly hired nurse caring for a pt who has a closed head injury, on a
| | | | | | | | | | | | | | |
vent, at risk for ICP--what action requires intervention? - CORRECT
| | | | | | | | | |
ANSWER✔✔-raising the foot of the pt beds-- maintain the head | | | | | | | | | |
midline/neutral position to prevent increased ICP | | | | |
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires
| | | | | | | | | | | | | |
intervention ? - CORRECT ANSWER✔✔-clustering pt care/activities--
| | | | | | |
cluster care= increased ICP | | |
assessing pts for the risk of sustaining TBI, which of the following pts
| | | | | | | | | | | | |
should the nurse identity as the greatest risk? - CORRECT ANSWER✔✔-
| | | | | | | | | |
20 year old college student who is on the football team.
| | | | | | | | | |
, Nurse w assigned pts. which assessment finding would need to be
| | | | | | | | | | |
reported to PCP? - CORRECT ANSWER✔✔-the development of
| | | | | | | |
asymmetric pupils with no reaction to light in the pt who has a TBI--
| | | | | | | | | | | | | |
pupillary changes; |
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the
| | | | | | | | | | | | | | | | |
pt has rhinorrhea and it is positive for glucose--what action is next? -
| | | | | | | | | | | | |
CORRECT ANSWER✔✔-perform a halo sign test--CSG leaking, lab test
| | | | | | | | |
will be analyzed for glucose and electrolyte content. place fluid on a
| | | | | | | | | | | |
while absorbent paper/linen
| |
nurse providing dc teaching to pts partner who sustained a mild head
| | | | | | | | | | | |
injury from MVC. --what statement requires additional teaching? -
| | | | | | | | |
CORRECT ANSWER✔✔-I will bring my partner to the ED if they
| | | | | | | | | | |
immediately start vomiting--symptoms usually resolve within 72 hrs NV
| | | | | | | | |
is expected.
|
Nurse is caring for the following pt. which pt would the nurse see first? -
| | | | | | | | | | | | | | |
CORRECT ANSWER✔✔-the pt who has a brain injury and a BP change
| | | | | | | | | | | |
from 110/58 to 134/40-- cushings triad. severe htn, widening pulse
| | | | | | | | | |
pressure, bradycardia |
24 hr post op craniotomy. pt is reporting headach 8/10-- what is the
| | | | | | | | | | | | |
next step for the nurse to take? - CORRECT ANSWER✔✔-perform a
| | | | | | | | | | |
neuro assessment--minimize ICP, assess the problem.
| | | | | |
