NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT/VERIFIED BEST EXAM SOLUTION GU, Exams of Nursing

Download NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT/VERIFIED BEST EXAM SOLUTION GU and more Exams Nursing in PDF only on Docsity! NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ • A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1. Vomiting continues 2. Intracranial pressure (ICP) is increased 3. The client needs mechanical ventilation 4. Blood is anticipated in the cerebralspinal fluid (CSF) 2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn’t strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ before signs and symptoms of ICP. • A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: 1. A cerebral lesion 2. A temporal lesion 3. An intact brainstem 4. Brain death 3. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits. • A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? 1. To reduce intraocular pressure 2. To prevent acute tubular necrosis 3. To promote osmotic diuresis to decrease ICP 4. To draw water into the vascular system to increase blood pressure 3. Mannitol promotes osmotic diuresis by increasing the NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern. • A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1. Urine output increases 2. Pupils are 8 mm and nonreactive 3. Systolic blood pressure remains at 150 mm Hg 4. ICP level of 12 4. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes, so urine output would increase; however, the reason mannitol was given was to decrease ICP. An ICP level of 12 is within normal limits. Fixed and dilated pupils are symptoms of increased ICP or cranial NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ nerve damage. No information is given that mannitol is being given for renal dysfunction or blood pressure maintenance. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 4. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle. • The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? 1. Side-lying, with legs pulled up and head bent down onto the chest 2. Side-lying, with a pillow under the hip NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 3. Prone, in a slight Trendelenburg’s position 4. Prone, with a pillow under the abdomen. 1. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae. • During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? 1. Limiting conversation with the child 2. Keeping extraneous noise to a minimum NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 3. Allowing the child to play in the bathtub 4. Performing treatments quickly 2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure. • Which of the following would lead the nurse to suspect that a NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 4. Lethargy 5. Increased appetite 6. Increased pulse 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor. • A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 3. Clear CSF, elevated protein, and decreased glucose 4. Clear CSF, decreased pressure, and elevated protein 2. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels. • A nurse is reviewing the record of a client with increased ICP and notes that the client has exhibited signs of decerebrate posturing. On assessment of the client, the nurse would expect to note which of the following if this type of posturing was present? NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 1. Abnormal flexion of the upper extremities and extension of the lower extremities 2. Rigid extension and pronation of the arms and legs 3. Rigid flexion of all extremities 4. Flaccid paralysis of all extremities 2. Decebrate posturing is characterized by the rigid extension and pronation of the arms and legs. 16. If a client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. body temperature control. b. balance and equilibrium. c. visual acuity. d. thinking and reasoning. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Intellectual functioning isn’t the only cerebral activity. Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Sensory function NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ testing involves assessment of pain, light-touch sensation, and temperature discrimination. 19. Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? a. In 30 to 45 seconds b. In 10 to 15 minutes c. In 30 to 45 minutes d. In 1 to 2 hours Answer B. When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Therefore, the dose can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the client’s risk of complications associated with status epilepticus. 20. A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign highest priority to which nursing diagnosis? a. Impaired physical mobility b. Ineffective breathing pattern c. Disturbed sensory perception (tactile) d. Self-care deficient: Dressing/grooming Answer B. Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ c. Inform the nurse manager. d. Call the physician immediately. Answer D. The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the client’s condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn’t necessary. 23. A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? a. Administer the ordered acetaminophen (Tylenol). b. Check the Foley tubing for kinks or obstruction. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ c. Adjust the temperature in the patient’s room. d. Notify the physician about the change in status. Answer: B – These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. Tylenol will not decrease the autonomic dysreflexia that is causing the patient’s headache. Notification of the physician may be necessary if nursing actions do not resolve symptoms. 24. A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment? a. Determine the level at which the patient has intact sensation. b. Assess the level at which the patient has retained mobility. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ c. Check blood pressure and pulse for signs of spinal shock. d. Monitor respiratory effort and oxygen saturation level. Answer: D – The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 – 5) innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary, but not as high priority. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterwards.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first? a. Place on the hospital alcohol withdrawal protocol. b. Transfer to radiology for a CT scan. c. Insert a retention catheter to straight drainage. d. Give phenytoin (Dilantin) 100 mg PO. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Answer: B – The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion. 28. The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the nurse finds that the patient’s blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the priority intervention? A. Start a large-bore IV in the patient’s arm B. Ask the patient for a stool sample C. Prepare to insert an NG Tube D. Administer intramuscular morphine sulphate as ordered A. Start a large-bore IV in the patient’s arm NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Correct – The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacement therapy, which requires a large bore IV. Ask the patient for a stool sample Incorrect – While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the priority intervention. Prepare to insert an NG Tube Incorrect – While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the first and priority intervention. Administer intramuscular morphine sulphate as ordered Incorrect – While this is an important intervention to manage pain, it is not the priority intervention. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ A. Keeping the extremity in a dependent position B. Monitoring distal pulses of the extremity C. Performing an escharotomy as a prophylactic measure D. Putting on sequential compression stockings B. Distal pulses on the extremity must be assessed to detect compartment syndrome A: Keeping the extremity in a dependent position will increase edema and compromise blood flow. C: Performing an escharotomy is a physician responsibility. D: Sequential compression devices should not be used in a burned extremity. Question 9 Type: MCMA NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Potassium supplementation 2. Testing for sources of infection 3. Increasing amount of NPH insulin administered NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 4. Increasing IV fluid administration 5. Monitoring arterial blood gases Correct Answer: 1,2,4 Rationale 1: HHS can cause either potassium deficit or excess. Potassium supplementation may be necessary. Rationale 2: Infection can cause HHS. Identification and management of causative factors is important. Rationale 3: HHS management requires administration of IV insulin. Rationale 4: HHS results in dehydration that is managed with IV fluids. Rationale 5: Monitoring patient’s level of consciousness Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Rationale 4: Assessment for paradoxical movement of the chest is part of the secondary survey, which occurs after the primary survey. The primary survey is not yet completed. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5 Question 15 Type: MCMA The nurse is providing care to a farmworker who was pinned against a steel gate by a horse. Deformation of the patient’s pelvis and femurs is obvious, but little blood is present on the patient’s clothing. Initial blood pressure is 110/68 mm Hg. What NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Initiate intravenous access with a 16 gauge catheter. 2. Start fluid resuscitation with normal saline. 3. Prepare to administer vasopressor medication. 4. Turn the patient to assess for injuries to the back. 5. Prepare to insert a chest tube. Correct Answer: 1,2 NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Rationale 1: This patient’s mechanism of injury and assessment indicates potential for femur and pelvic fractures, which can result in massive blood loss. The “normal” blood pressure may be related to pain and adrenaline release. Venous access with large gauge catheters is essential. Rationale 2: This patient may be bleeding internally. Fluid resuscitation is indicated. Rationale 3: Vasopressor medications are not useful until fluid volume is restored. Rationale 4: This patient should not be moved until further assessment is conducted. Rationale 5: Nothing in the patient’s assessment indicates need for a chest tube at this point. The nurse should continue to assess airway and breathing. Global Rationale: NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-7 Question 20 Type: MCSA A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which post-traumatic complication should the nurse focus on when providing care to this patient? 1. Abdominal compartment syndrome NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 2. Sepsis 3. ARDS 4. Acute renal failure Correct Answer: 3 Rationale 1: Abdominal compartment syndrome is more common in patients with abdominal trauma. Rationale 2: Sepsis is more common in patients with abdominal trauma or open wounds. Rationale 3: The patient with a thoracic injury is prone to developing the post- traumatic complications of ARDS and DIC. Rationale 4: Acute renal failure can occur with any massive trauma that involves blood loss, but is more common if injuries to the abdomen exist. Global Rationale: NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34-8 Question 2 Type: MCSA A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position? 1. The brain will compress the cerebral veins less in this position. 2. The ventricles of the brain will drain better in this position. 3. This position allows for less pain for the patient. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 3. Fever 4. Paralysis Correct Answer: 3 Rationale 1: Sedation will decrease cerebral blood flow. Rationale 2: Hypothermia will decrease cerebral blood flow. Rationale 3: Fever increases the body’s metabolic rate and will increase cerebral blood flow. Rationale 4: Paralysis, often initiated chemically, will decrease cerebral blood flow. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-1 Question 4 Type: MCSA The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable? 1. There will be an increase in the blood flow to the brain. 2. There is a decrease in the blood–brain barrier. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 3. There must be a decrease in another of the intracranial compartments. 4. There will be an increase in the production of cerebrospinal fluid. Correct Answer: 3 Rationale 1: Blood flow to the brain would decrease as more space is taken up by the brain. Rationale 2: The blood–brain barrier does not increase or decrease in response to changes in the brain. Rationale 3: The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro–Kellie hypothesis states that as the content of one of the intrancranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments. Rationale 4: An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-2 Question 7 Type: MCSA A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient? 1. 50 mm Hg 2. 90 mm Hg NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 3. 70/40 mm Hg 4. 40/70 mm Hg Correct Answer: 1 Rationale 1: The cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure. In this patient the cerebral perfusion pressure would be inadequate and intervention is needed. Rationale 2: This calculation is incorrect for the values given. Rationale 3: This calculation is incorrect for the values given. Rationale 4: This calculation is incorrect for the values given. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Assessment Learning Outcome: 15-3 Question 8 Type: MCSA A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status? 1. The patient cannot remember where he is. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 4. 9 Correct Answer: 3 Rationale 1: A score of 11 indicates some impairment, but does not indicate coma. Rationale 2: A GCS of 15 is normal. Rationale 3: A score of 7 or less indicates a significant alteration in the level of consciousness and the development of coma. Rationale 4: A GCS score of 9 indicates significant neurological changes, but does not indicate coma. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 19 Type: MCSA A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse? 1. Document the presence of decorticate posturing. 2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ reading. 3. Assess the position of the patient’s arms. 4. Administer intravenous sedation as quickly as possible after access is obtained. Correct Answer: 3 Rationale 1: It is not possible to assess decorticate posturing from this scenario. Rationale 2: It is important to gain IV access for this patient. Posturing to noxious stimuli indicates brain damage. Blood pressure is not pertinent at this time. Rationale 3: The nurse should assess the position of the patient’s arms to determine if decorticate or decerebrate posturing is present. Rationale 4: Administering sedation is not indicated at this time as assessment is continuing. Global Rationale: NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Rationale 2: Stroke is the third cause of death and a leading cause of disability in the United States. Rationale 3: There is no evidence that stroke and MI generally occur together. Rationale 4: Rapid recognition of stroke symptoms along with rapid intervention can help to decrease poor outcomes from stroke. Rationale 5: Neurological changes and deficits are common when stroke occurs. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-1 Question 2 Type: NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ MCSA A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient? 1. If the patient has high blood pressure 2. If the symptoms are still present 3. If this is a recurrent problem NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 4. If the patient fell Correct Answer: 2 Rationale 1: Although important, determining if the patient has a history of high blood pressure can be determined at a later time. Rationale 2: Although all of these issues are important in the assessment of the patient, it is essential to determine if the patient still has the symptoms or if they were time limited. If symptoms are no longer present they are still significant as the patient may have experienced a transient ischemic attack. Rationale 3: It is important to discern if the patient has ever experienced these symptoms before, but this is not the most important information. Rationale 4: Assessing if the patient has fallen is not important for the nurse to ask initially. Global Rationale: NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-1 Question 4 Type: MCSA When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management? 1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain 2. Keeping the blood pressure under control pharmacologically 3. Transferring the patient for rehabilitation as soon as medically stable NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 4. Reestablishing blood flow to the infarcted area surgically Correct Answer: 1 Rationale 1: The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover. Rationale 2: The patient’s blood pressure should be controlled, but this goal is not global enough to be the primary goal. Rationale 3: Transferring the patient to a long-term care facility as soon as medically stable is a goal for patients to recover enough function to return to their former settings. This is not the primary goal for medical management. Rationale 4: Surgical options are not available for most stroke patients. Global Rationale: Cognitive Level: Analyzing NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-5 Question 12 Type: MCSA A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family? NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Insert a nasogastric tube for nutritional support. 2. Monitor for renal stone formation. 3. Monitor for deterioration of neurological status. 4. Reposition every 15 minutes. Correct Answer: 3 NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Rationale 1: Insertion of a nasogastric tube can cause injury and should be avoided in this patient. Rationale 2: Renal stone formation is not a complication of this medication. Rationale 3: Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation. Rationale 4: Frequent moving can increase the risk of bleeding therefore the patient should not be repositioned every 15 minutes. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-6 Question NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 1 Type: MCSA A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic “about 6 weeks ago.” The nurse would ask additional assessment questions regarding which condition? 1. Acute subdural hematoma 2. Subacute subdural hematoma 3. Epidural hematoma 4. Chronic subdural hematoma Correct Answer: 4 Rationale 1: An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Correct Answer: 4 Rationale 1: Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered. Rationale 2: Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness. Rationale 3: Fine crackles auscultated bilaterally in lung bases can be due several conditions, such as immobility, and is not indicative of an emergent neurological condition. Rationale 4: Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-3 Question 5 Type: MCSA A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient? 1. Electrolyte replacements NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 2. Maintain adequate fluid volume. 3. Supporting nutritional needs 4. Maintain stable cerebral perfusion pressure. Correct Answer: 4 Rationale 1: Electrolyte management is important to patients with head injury but is not the intervention of highest priority. Rationale 2: Fluid volume management is important when caring for patients with brain injury, but is not the highest priority. Rationale 3: Support of nutritional needs is important for all patients, but is not the intervention of highest priority for patients with brain injury. Rationale 4: Since diffuse head injuries are not limited to a localized area, this makes them more difficult to detect and treat. Management in the acute care phase includes diligent and frequent neurological assessments and pain management. When moderate-to-severe injury is present, priority management includes NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Rationale 3: Eventually the body will rid itself for debris from death of any cells, but this is not the immediate goal. Rationale 4: The first goal in treating traumatic brain injury is to limit the primary ischemic tissue injury by aggressive prevention and treatment of hypoxia and hypotension. If efforts to meet this goal are successful, cerebral swelling neuronal death and cerebral inflammation can be limited as well. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18-5 Question 7 Type: MCMA NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in level two interventions to reduce intracranial pressure (ICP) through which uses of this catheter? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Assessing of color of the cerebral spinal fluid 2. Assessing of the amount of cerebral spinal fluid 3. Instillation of hyperosmolar therapy via the catheter 4. Draining CSF 5. Directly monitoring the ICP NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Correct Answer: 1,2,4,5 Rationale 1: By assessing the color of the cerebral spinal fluid the nurse can identify variation from normal. These variations may indicate bleeding or infection that would increase ICP. Rationale 2: By using IVC measurements, the nurse can monitor amount of CSF. Rationale 3: Hyperosmolar therapy is not instilled via this catheter. Rationale 4: Therapeutic drainage of CSF via the IVC can reduce ICP. Rationale 5: Insertion of an IVC allows for direct measurement of the ICP. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18-5 Question 10 Type: MCSA A patient being treated for increased intracranial pressure from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient? NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ 1. “We will let this patient rest between his bath and changing his linens.” 2. “We are going to bath this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon.” 3. “Be certain that we don’t raise this patient’s head above 10 degrees during his bath.” 4. “You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds.” Correct Answer: 1 Rationale 1: When simple activities result in an increase in intracranial pressure it is necessary to space care in such a way to allow the patient’s ICP to recover between events. Rationale 2: Stacking care activities will be detrimental to this patient. Rationale 3: The head of the bed should be elevated to 30 degrees to reduce intracranial pressure without compromising cerebral perfusion pressure. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Rationale 4: The patient should be suctioned for 10 seconds or less to reduce an increase in intracranial pressure caused by the suctioning. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-6 Question 11 Type: MCMA The admission orders for a patient with traumatic brain injury say to keep the patient’s head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement? NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18-6 Question 12 Type: MCSA A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention? 1. Culture the patient’s urine. 2. Contact the primary health care provider. 3. Administer the prn antipyretic. 4. Have the patient cough and deep breath more frequently. Correct Answer: 3 NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Rationale 1: Urinary tract infection will cause increased temperature and this may be a necessary intervention. It is not, however, the primary intervention. Rationale 2: It is important to keep the primary health care provider apprised of the patient’s condition, but this is not the primary intervention. Rationale 3: Hyperthermia will increase cerebral metabolic rates, which will increase cerebral oxygen demands. The patient with a temperature should be provided with antipyretics or other measures to cool the body and reduce the temperature. Rationale 4: Implementing pulmonary hygiene activities will not reduce the patient's body temperature. NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-6 Question 13 Type: MCMA The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation? Note: Credit will be given only if all correct choices and no incorrect choices are selected.