Exam 4: NUR209 NUR 209 New Update Medical Surgical Nursing II

Exam 4: NUR209/ NUR 209 (New 2024/

2025 Update) Medical Surgical Nursing II | Questions and Verified Answers| 100% Correct| A Grade – Fortis

QUESTION

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

Answer:

Blood pressure 154/68, pulse 56, respirations 12

QUESTION

An unconscious patient is admitted to the ed with a head injury. The pa- tient's spouse and teenage children stay at pt's side and ask many questions about the treatment

Answer:

Allow the family to stay with the patient and briefly explain all procedures to them

QUESTION

A 20-year old make patient is admitted with a head injury after a collision while playing football, after noting the patient has developed clear nasal drainage, which action should the nurse take?

Answer:

Check drainage for glucose content

QUESTION

A patient who has suspected epidural hematoma is admitted to the emer- gency department.Which action will the nurse expect to take?

Answer:

Prepare the patient for craniotomy

QUESTION

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

Answer:

Encourage immunization for adolescent and college freshmen

QUESTION

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient

Answer:

Risk for aspiration

QUESTION

The home health nurse caring for an 81 year old

Answer:

provide support to the spouse caregiver

QUESTION

A patient in the emergency department with sudden onset right sided weakness is diagnosed with an intracerebral hemorrhage

Answer:

The patient has atrial fibrillation and takes warfarin

QUESTION

When caring for a patient who has experienced a T2 spinal cord transec- tion

Answer:

urinary catheter care continuous cardiac monitoring maintain a warm room temperature administer H2 receptor blockers

QUESTION

What information would the nurse seek from a patient with newly diag- nosed trigeminal neuralgia?

Answer:

Triggers leading to facial discomfort

QUESTION

A patient is being admitted with possible stroke. Which information from the assessment indicates that the nurse should consult with the hcp before giving a prescription dose of aspirin

Answer:

The patient reports that the symptoms began with a severe headache

QUESTION

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to

Answer:

Respect the patient's desire and arrange for privacy at mealtimes

QUESTION

A 70 year old female patient with left-sided hemiparesis arrives by ambu- lance to emergency department.

Answer:

Check respiratory rate and effort

QUESTION

Which preventative actions by the nurse will help limit the development of systemic inflammatory response syndrome SATA

Answer:

use aseptic technique when caring for invasive line or device ambulate postoperative patients asap remove indwelling urinary catheter asap after surgery administer prescribed antibiotics within 1 hour

QUESTION

While ambulating in the room, a patient complains of feeling dizzy.. in order

Answer:

have the patient sit down take the patient's blood pressure give the patient something to drink notify pcp

QUESTION