NUR 265 Exam 3 Questions & Answers Solved 100% Correct!!

The nurse is caring for an adult client who was recently admitted with a head injury following a motor vehicle crash. One hour ago, the client's vital signs (VS) were temperature (T): 98.6° F; pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of the following findings is a priority for the nurse to follow up? a) P: 90; R: 32; BP: 130/72 mm Hg.- b) P: 120; R: 26, BP: 110/70 mm_ Hg. c) P: 56; R: 14; BP: 166/52 mm Hg. d) P: 64, R: 30; BP: 148/78m Hg. 2.) The nurse is caring for a client who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing increased intracranial pressure (ICP). Which of the following actions should the nurse take when caring for this client? a) Perform passive range of motion (ROM) to the client's hips and knees. b) Log roll the client during turning and repositioning. c) Elevate the foot of the client's bed. d) Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg. 3.) The newly hired nurse is caring for a client who was admitted 12 hours ago with a traumatic brain injury (TBI), is intubated, and is at risk for developing increased intracranial pressure (ICP). Which interventions from the box below should the nurse include in the client's plan of care? 1 Avoid clustering client care activities. 2 Maintain the head in a flexed position. 3 Provide a quiet environment by limiting visitors. 4 Have the client cough and deep breathe every hour. 5 Hyper oxygenate the client before and after suctioning. 6 Avoid maintaining hips in a flexed position. 4.) The nurse working in the intensive care unit (ICU) is assessing a client who sustained a basilar skull fracture 24 hours ago. It is most important to follow up with the primary health care provider (PHCP) if the client a) Becomes irritable and restless. b) Has bruises under the eyes. c) Is unable to name the state capital. d) Reports having a persistent headache since admission. 5.) The nurse is assessing a client who has experienced a mild traumatic brain injury (TBI). Which findings from the box below are consistent with this diagnosis? 1 Dizziness and gait problems. 2 A widened pulse pressure. 3 Increased sensitivity to light or noise. 4 A Glasgow Coma Scale (GCS) score of 9. 5. Dilated pupils that are nonreactive to light. 6. Amnesia about the events around the time of injury. 6.) The nurse is providing discharge instructions to the parents of a 15-year-old female who sustained a concussion while plaving field back Which of the following statements by a parent indicates a need for further teaching? a) "We should avoid giving any acetaminophen to treat headaches. b) "We need to bring our daughter back te the emergency department if she exhibits blurred vision." c) "We should provide a consistent routine at home to assist with any behavior changes." d) "We will not allow our daughter to engage in strenuous activity for at least 48 hours."