nurs 220 exam 3 Actual Exam Latest Update

nurs 220 exam #3 Actual Exam Latest Update

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A 6 year old male fell 6 feet from a tree. He is awake and has the ability to move all of his extremities. When you ask what happened he tells you that he sell and then begins

to tell you about his pet dog - CORRECT ANSWER: 15 perfect

A 17 year old male overdosed on narcotics. He looks around with an unfocused gaze, mumbles when you ask him questions, and pulls away from painful stimulus. What is his

glascoma scale - CORRECT ANSWER: 10 (eye3, speech 3 verbal, motor 4 withdraws)

A 20 year old female sell 20 feet while rock climbing when you apply a sternal rub she

extends her arms and legs and butt shows no other response - CORRECT ANSWER: 4

(eye1, verbal1, motor2)

A 21 year old male is extremely intoxicated . When you attempt to insert a nasal airway he slaps your hand away. Curses at you, and then set up. When you remove the air way he lies down on the stretcher what is his Glasgow Coma Scale - CORRECT ANSWER: 11 (eye opening 1 none, verbal 5 oriented motor, 5 purposeful movement to painful stimulus)

A 24 year old female overdosed on an unknown substance. She is staring off into space, babbling, when you apply painful stimulus she cries out in comprehensibly but

does not pull away - CORRECT ANSWER: 9 (eye2 reaction to pain, verbal 2

incomprehensible speech, motor 5 localizes)

A 28 year old female with a closed head injury moans and bends her arms towards her chest. She points her toes when you attempt to splint a extremity fracture. What is her

gcs - CORRECT ANSWER: 6 (eye1, verbal 2 incomprehensible speech, motor 3

abnormal flexion decorticate posture)

a 37 year old female is intoxicated and fractured her leg when you apply a splint she looks at you and withdraws her legs then Grunts in pain - CORRECT ANSWER: 8 (eye2 opens to pain, verbal 2 confused convo but able to answer questions, motor 4 obeys commands for movement)

A 44 year old female fell off a roof. She answers your commands within comprehensible sounds. When you pinch her trapezoid her eyes do not open but she moves her legs

what is her Glasgow Coma Scale - CORRECT ANSWER: 7(eye1 no response, verbal 2

incomprehensible sounds, motor 4 withdraws from pain but not purposefully)

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A 56 year old male rubs his abdomen and tells you it really hurts he tells you that he wants to go to the hospital and you help him walk to the stretcher what is his Glascow

Coma Scale - CORRECT ANSWER: 15

A 64 year old male looks at you when you speak to him when you ask him the date he says blue, he has left sided weakness when he grips your fingers - CORRECT

ANSWER: 13 (eye4, verbal3, motor6)

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?

• Prepare to administer recombinant tissue plasminogen activator (rt-PA).
• Discuss the precipitating factors that caused the symptoms.
• Schedule for a STAT computed tomography (CT) scan of the head.

4. Notify the speech pathologist for an emergency consult. - CORRECT ANSWER: 3

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?

• Administer a stool softener b.i.d.
• Encourage the client to cough hourly.
• Monitor neurological status every shift.

4. Maintain the dopamine drip to keep BP at 160/90. - CORRECT ANSWER: 1

A patient's blood pressure 92/56 and ICP 6. What is the patient's cerebral perfusion pressure and how do you interpret this finding?

• 82 mmHg, normal
• 56 mmHg, low
• 62 mmHg, normal

D. 108 mmHg, high - CORRECT ANSWER: C

The MAP is 68. When you calculate the equation: CPP=68-6, you get 62 mmHg as the CPP. Remember a normal CPP is 60-100 mmHg.

A patient's blood pressure is 80/42 and ICP 22. What is the patient's cerebral perfusion pressure and how do you interpret this finding?

• 33 mmHg, low
• 30 mmHg, normal
• 48 mmHg, low

D. 64 mmHg, normal - CORRECT ANSWER: The MAP is 55. When you calculate the

equation: CPP=55-22, you get 33 mmHg as the CPP. Remember a normal CPP is 60-

100 mmHg.

A patient's blood pressure is 110/74 and ICP is 8. What is the patient's cerebral perfusion pressure?

• 94 mmHg 2 / 4

• 56 mmHg
• 98 mmHg

D. 78 mmHg - CORRECT ANSWER: D

The MAP is 86. When you calculate the equation: CPP= 86-8, you get 78 mmHg as the CPP.

A patient's blood pressure is 152/96 and ICP is 20. What is the patient's cerebral perfusion pressure?

• 115 mmHg
• 20 mmHg
• 95 mmHg

D. 56 mmHg - CORRECT ANSWER: C

The MAP is 115. When you calculate the equation: CPP= 115-20, you get 95 mmHg as the CPP.

A patient's mean arterial pressure is 82 and ICP is 15. What is the patient's cerebral perfusion pressure?

• 67 mmHg
• 100 mmHg
• 52 mmHg

D. 30 mmHg - CORRECT ANSWER: A

The MAP is 82. When you calculate the equation: CPP= 82-15, you get 67 mmHg as

the CPP.

An 81 year old male is pulseless a nap nick is lying supine in bed with dried blood in his

nose and ears - CORRECT ANSWER: 3

An 85 year old male is in a nursing home and walking around his room and greet you when you answer. He speaks clearly but his answers are confusing and rambling -

CORRECT ANSWER: 14 (eye4, verbal 4 confused, motor 6 obeys commands)

And 30 year old male was found on the sidewalk outside a homeless shelter when you applied painful stimuli he opens his eyes tells you to go away and then he pushes your

hand away - CORRECT ANSWER: 12 (eye2, verbal5, motor5)

Benzodiazepines are indicated in the treatment of cases of delirium that have which

cause - CORRECT ANSWER: Alcohol withdrawal

In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock?

• No reflex activity below the waist.
• Inability to move upper extremities.
• Complaints of a pounding headache.

4. Hypotension and bradycardia. - CORRECT ANSWER: 1

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The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority?

• Assess lung sounds.
• Assess the six cardinal fields of gaze.
• Assess apical pulse.

4. Assess level of consciousness. - CORRECT ANSWER: 4

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?

• The client will return to work within six (6) months.
• The client is able to focus and stay on task for 10 minutes.
• The client will be able to dress self without assistance.

4. The client will regain bowel and bladder control. - CORRECT ANSWER: 2

The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client?

• "Have you experienced any difficulty with your menstrual cycle?"
• "Have you noticed a rash across the bridge of your nose?"
• "Do you get tired easily and sometimes have problems swallowing?"
• "Are you taking birth control pills to prevent conception?" - CORRECT ANSWER: 3

The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement?

• Refer the client to the American Spinal Cord Injury Association (ASIA).
• Refer the client to the state rehabilitation commission.
• Ask the social worker about applying for disability.
• Suggest that the client talk with his significant other about this concern. - CORRECT

ANSWER: 2

The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented?

• Consult the physical therapist for assistive devices for mobility.
• Determine if the client has a legal power of attorney.
• Ask if the client would like to talk to the hospital chaplain.

4. Discuss the client's wishes regarding end-of-life care. - CORRECT ANSWER: 4

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