NUR390 NUR 390 EXAM 3

NUR390 / NUR 390 EXAM 3

Nursing Care of Adult I Concordia, St. Paul Actual Questions and Answers

This Exam contains:

➢ 100% Guarantee Pass.➢ Actual Questions and Answers ➢ Multiple choice (single best answer) ➢ Case Studies/Scenario-Based Questions

• / 4

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which statement by the nurse would be the best initial response for this situation?

• "This is a complex type of monitoring system, and it is managed by

skilled staff."

• "The system measures pressures to determine whether blood flow

to the brain is adequate"

• "The ventriculostomy monitoring system helps check for changes

in cerebral perfusion pressure."

• "This monitoring system has many benefits, including the ability to

drain cerebrospinal fluid." Answer

• "The system measures pressures to determine whether blood flow to the

brain is adequate"

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 10 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

• Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12

breaths/min 2 / 4

• Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32

breaths/min

• Blood pressure 148/78 mm Hg, pulse 12 beats/min, respirations 28

breaths/min

• Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30

breaths/min Answer

• Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12

breaths/min When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how would the nurse report the response?

• Flexion withdrawal
• Localization of pain
• Decorticate posturing
• Decerebrate posturing

Answer

• Decorticate posturing

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter would the nurse monitor to determine the medication's effectiveness?

• Blood pressure
• Oxygen saturation 3 / 4

• Intracranial pressure
• Hemoglobin and hematocrit

Answer

• Intracranial pressure

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?

• 9
• 11
• 13
• 15

Answer

• 11

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment.Which action is best for the nurse to take?

• Call the family's pastor or spiritual advisor ot take them to the

chapel.

• Ask the family to stay in the waiting room until the assessment is

completed.

• Allow the family to stay with the patient and briefly explain all
• / 4