NURSING MISC Literally Exam 3 265 correct answers

#1: The nurse is working in the emergency department (ED) is admitting a client who has sustained a traumatic brain injury (TBI) following a motor vehicle crash. It is priority for the nurse to notify the primary healthcare provider (PHCP) in the client: Takes prescribed warfarin daily. RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment of impact. Warfarin is a blood thinner and the patient may bleed out if they have a hematoma (a collection of blood) #2: The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following actions, if performed by the newly hired nurse, requires intervention by the charge nurse? Raising the foot of the client’s bed. RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP. #3: The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed Clustering client care activities RATIONALE: pg. 2387. When multiple activities are clustered in a row, the effect on ICP can be dramatic elevation. #4: The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should the nurse identify as being at greatest risk? 20 year old college student who participates on the football team. RATIONALE: Pg. 2397. A force produ