Exam 3 Practice Questions & Rationales For Nur 265: Complex Mobility & Cognition Complete

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EXAM 3 PRACTICE QUESTIONS & RATIONALES FOR NUR 265:
COMPLEX MOBILITY & COGNITION COMPLETE

1.) Thenurseiscaringforanadultclientwhowasrecentlyadmittedwithaheadinjuryfoll owin
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g a motor vehicle crash. One hour ago, the client's vital signs (VS) were temperature (T
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): 98.6° F; pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mmHg.Whicho fthefo
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llowingfindingsisapriorityforthe nurse tofollowup? c
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P:90; R: 32; BP: 130/72 mmHg.-
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P:120;R: 2 6,BP: 1 10/70mm_Hg. P: n
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56;R:14;BP:166/52mmHg. P
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:64,R: 3 0; BP:148/78mHg. n
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2.) The nurse is caring fora client who sustained a closed head injury, is receiving mechanic alven
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tilation,andisatriskfordevelopingincreasedintracranialpressure(ICP).Whichoft hefollowi
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ng actions should thenursetakewhencaringforthisclient?
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Performpassiverangeofmotion(ROM)totheclient'shipsandknees.Logro llt n
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heclientduring turningandrepositioning.
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Elevatethefootoftheclient'sbed.
Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
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3.) The newly hired nurse is caring for a client who was admitted 12 hours ago witha traum atic
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brain injury (TBI), isintubated, and is at risk for developing increased intracranial pre ssure(I
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CP).
Whichinterventionsfromtheboxbelowshouldthenurseincludeintheclient's plan of car c n c n c n c n




e?
1 Avoidclustering c lient careactivities. n
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2 Maintain the head inaflexed position. n
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3 Providea quietenvironment by limiting visitors. n
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4 Have the client cough and deep breathe every hour. cn cn cn cn cn cn cn cn




5 Hyper oxygenate the client before and aftersuctioning. cn cn cn qw cn cn




6. Avoidmaintaining hips in aflexed position. n
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1,3,4,5.n
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1,3,5,6.n
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1,2,4,6.n
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2,4,6. n
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4.) Thenurseworkingintheintensivecareunit(ICU)isassessingaclientwhosustaineda basi
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lar skullfracture 24 hours ago. It is most important to follow up with the primary healt hcare pr
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ovider (PHCP)ifthe client cn c
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becomesirritableandrestless.has bruise n
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sundertheeyes. n
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is unable to name the state capital.
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reports having a persistent headache since admission.
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5.) Thenurseisassessing aclient who hasexperienced amild traumatic brain injury(TBI)
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.Whichfindingsfromthebox below are consistent withthisdiagnosis?
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1 Dizziness and gait problems. cn cn cn




2 Awidened pulse pressure. cn cn




3 Increased sensitivity to light or noise. cn cn cn cn cn




4 AGlasgowComaScale(GCS)scoreof9. w
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5 Dilatedpupilsthat arenopreactive tolight. c
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6 Amnesiaabouttheevents around thetimeofinjury. c
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1,3,6. n
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3,5,6. n
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2,3,4,5. n
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1,2,4,6. n
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6.) The nurse is providing discharge instructions to the parents of a 15-year-
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oldfemalewhosustainedaconcussion whileplavingfieldback
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Whichofthe following statements by aparent indicates aneedforfurtherteaching? cn cn cn cn cn cn




"We should avoid giving any acetaminophen to treat headaches.
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"We need to bring our daughter back te the emergency department if she exhibits blurred vision."
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"Weshouldprovideaconsistent routineathometo assist withanybehaviorchanges.""Wewil l not n
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allowourdaughtertoengageinstrenuousactivityforatleast48hours."
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7.) The nurse is assessing clients for the risk of sustaining a traumatic brain injury (TBI). Whi
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chofthefollowingclientsshouldthenurseidentifyasbeing atgreatestrisk?
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45-year-old who has epilepsy and takes phenytoin. c n c n c n c n c n c n




75-year-old who lives alone and has macular degeneration. cn cn c n c n c n c n c n




7-year-oldwhoislearninghowtorideabicyclewithouttrainingwheels.20-
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year-oldcollegestudent whoparticipatesonthetennisteam.
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8.) The nurse is providing discharge instructions to the partner of a client who sust aine
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d a mild head injury as a result of a motor vehicle crash. Which of the following statem
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entsbyapartnerindicates aneed forfartherteaching?
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"Itisexpectedthatmypartnerwillhavedrainagefromthenoseforthenext fewdays.""Iwill p rovid
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emypartnerwithaeetaminophenevery4hoursforheadache."
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"I will ensure my partner avoids strenuous activity for the next 48 hours."
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"Iwill avoid giving my partner their scheduled lorazepam for at least the next 24 hours."
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9.) The nurse is caring for a client who is postoperative following a craniotomy and hasdev elop
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ed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following a ctionss
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hould the purse take? c
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Remove salt packets from the client's meal tray. Chan
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geIVfluidsto0.45%sodiumchloride(half-
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strengthsaline).Initiateaprescribedfluidrestriction.
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Administer oral desmopressin acetate. cn cn cn




10.) The nurse iscaring for the following assigned clients. Which client should the nurs ese
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efirst?
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The client who has bacterial meningitis and has become lethargic.
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Theclientwhohasamildtraumaticbraininjury(BI)andis reporting dizzinessandinsomnia. Thecli
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entwhohasaconcussionandisirritableandreportingaheadache.
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Theclientwhohasaskullfracture,isalertandoriented,andreportsfeelingnauseated. qw




11.) The nurse iscaring for a client who hasmeningitis. It isa priority for the nurse to follow upif
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reportsthedevelopment offatigue. hasa changeinGlasgowComaScale(GCS)scorefro
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m12to14overthepast4 hours. hasachangeinbloodpressure(BP)from132/75to160 c n c n n
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/56mmHg.reportss ensitivitytolight.
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12.) The nurse is admitting a client who is diagnosed with bacterial meningitis. Which ofth e fo
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llowing actions should the nurse take first?
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Assesstheeyesforpupillaryshapeandmovement.Teach t
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heclientabouttheconditionandtreatment. n
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Determinewhotheclient has beenincontactwith. Adminis ter n
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an antiepileptic medication. qw




13.) The nurse working inthe emergency department (ED) is admitting a client who isa coll ege
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studentandlivesinadormitory.Theclienthaschills,nuchalrigidity,anda
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