The nurse is caring for a patient with increased intracranial pressure (ICP). Which action
would be considered to be a collaborative intervention?
a. Decreasing perfusion
b. Administering an osmotic diuretic
c. Assessing orientation
d. Assessing for edema correct answer: ANS: B
Which asses...
BSN 246 HESI Physical Assessment Questions
With Complete Solutions
The nurse is caring for a patient with increased intracranial pressure (ICP). Which action
would be considered to be a collaborative intervention?
a. Decreasing perfusion
b. Administering an osmotic diuretic
c. Assessing orientation
d. Assessing for edema correct answer: ANS: B
Which assessment finding would be the earliest and most sensitive indicator that there is an
alteration in intracranial regulation?
a. Change in level of consciousness
b. Inability to focus visually
c. Loss of primitive reflexes
d. Unequal pupil size correct answer: ANS: A Change in level of consciousness
When caring for a patient after a head injury, the nurse would be
most concerned with
assessment findings which included respiratory changes along with what other findings?
a correct answer: A. Hypertension and Bradycardia
Which components of the Glasgow Coma Scale (GCS) should the nurse use to assess a patient after a head injury? correct answer: D. Verbal Responsiveness
The nurse is teaching a patient about head injuries. Which information should the nurse
include as a primary prevention strategy to reduce the occurrence of head injuries? correct answer: D. Violence Prevention
The nurse preparing to care for a patient after a suspected stroke would question which
order? correct answer: a. Antihypertensive
After shunt procedure, the nurse would monitor the patient's neurologic status by using
which test? correct answer: b. Glasgow Coma Scale
A patient presents to the emergency room complaining of vomiting with severe back and leg pain. The patient's home medications include daily oral corticosteroids. Vital signs reveal a
low blood pressure and there are peaked T waves on the electrocardiogram. What is the
nurse's priority intervention? correct answer: a. Start an intravenous line
Which important teaching point should the nurse include in the plan of care for a patient
diagnosed with Cushing disease?
a. Daily weight using same scale
b. Wash hands frequently c. Use exfoliating soaps when bathing
d. Avoid yearly influenza vaccine correct answer: ANS: B
Cushing syndrome is characterized by chronic excess glucocorticoid (cortisol) secretion
from the adrenal cortex. This is caused by the hypothalamus, or the anterior pituitary gland,
or the adrenal cortex. Cushing syndrome can also be caused by taking corticosteroids in the
form of medication (such as prednisone) over time4referred to as exogenous Cushing
syndrome. Regardless of the cause, excess secretion of cortisol has a systemic affect
affecting immunity, metabolism, and fat distribution (truncal obesity), reduced muscle mass,
loss of bone density, hypertension, fragility to microvasculature,
as well as thinning of the
skin. Washing hands is important because the patient's immune system is suppressed due to
the excess glucocorticoid level. Daily weights are not indicated. Exfoliating soaps may
damage thin skin. The patient should receive vaccinations due to
being
immunocompromised
The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic
hormone (SIADH). What is the nurse's best action?
a. Encourage increased fluid and water intake
b. Teach about risk for malignancies
c. Monitor for changes in level of consciousness d. Assess labwork for potassium level changes correct answer: ANS: C
As the name suggests, SIADH is a condition in which antidiuretic hormone (ADH) is
secreted despite normal or low plasma osmolarity, resulting in water retention and dilutional
hyponatremia. In response to increased plasma volume, aldosterone secretion increases and
further contributes to sodium loss. Hyponatremia frequently manifests with changes in level
of consciousness from confusion to coma. A large number of clinical conditions can cause
SIADH including malignancies, pulmonary disorders, injury to the brain, and certain
pharmacologic agents. Malignancies often lead to SIADH versus
SIADH causing malignant
conditions. Water intoxication can lead to hyponatremia, therefore water intake is restricted.
The most affected electrolyte from SIADH is sodium versus potassium.
Following a parathyroidectomy, which electrolyte should the nurse most closely monitor?
a. Potassium
b. Sodium
c. Magnesium
d. Calcium correct answer: d. Calcium Because the parathyroids are located on the thyroid gland, similar concerns for
postoperative monitoring apply. Additionally, calcium levels are
monitored to avoid
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