NUR2243 Exam 3
1.A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed. - ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure
to decrease the clients risk for infection.
2.A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds. - ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation. 3.The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?
a. Aligning the neck with the body
b. Clustering many nursing activities
c. Elevating the head of the bed 30 degrees
d. Providing stool softeners or laxatives as ordered - ANS: B It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.
4.The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be
a. change in level of consciousness.
b. inability to focus visually.
c. loss of primitive reflexes.
d. unequal pupil size. - ANS: A
A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.
5.When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, a. hypertension, and bradycardia.
b. hypertension, and tachycardia.
c. hypotension, and bradycardia.
d. hypotension, and tachycardia. - ANS: A
Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushings triad). It is bradycardia, not tachycardia, which is the component of
this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.
6.Components of the GCS the nurse would use to assess a patient after a head injury include
a. blood pressure.
b. cranial nerve function.
c. head circumference. d. verbal responsiveness. - ANS: D
Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.
7.Primary prevention strategies to reduce the occurrence of head injuries would include
a. blood pressure control.
b. smoking cessation.
c. maintaining a healthy weight.
d. violence prevention. - ANS: D
Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure
control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy
which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.
8.The nurse preparing to care for a patient after a suspected stroke would question an order for a(n)
a. antihypertensive
b. antipyretic
c. osmotic diuretic
d. sedative - ANS: A Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.
9.After shunt procedure, the nurse would monitor the patients neurologic status by using the
a. electroencephalogram
b. GCS
c. National Institutes of Health Stroke Scale.
d. Monro-Kellie doctrine. - ANS: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This
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