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+  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 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+ clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained 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 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. A negative Kernig’s sign 3. Absence of nuchal rigidity 4. A Glascow Coma Scale score of 15 1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski’s sign, and positive Kernig’s sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig’s sign is positive when the client feels pain and spasm of 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. 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 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 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. 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 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 nerve damage. No information is given that mannitol is being 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. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure 3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there’s damage to the posterior pituitary.  The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain? 1. Sternal rub 2. Pressure on the orbital 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+ rim 3. Squeezing the sternocleidomastoid muscle 4. Nail bed pressure 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 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. 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+ startling the child and subsequently increasing intracranial pressure.  Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? 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. Hemorrhagic skin rash 2. Edema 3. Cyanosis 4. Dyspnea on exertion 1. DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.  The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1. Head tilt 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. Vomiting 3. Polydipsia 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 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. 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. visual acuity. d. thinking and reasoning. Answer A. The body’s thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum. 17. After striking his head on a tree while falling from a ladder, a young man, age 18, is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? 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. Give him a barbiturate. b. Place him on mechanical ventilation. c. Perform a lumbar puncture. d. Elevate the head of his bed. Answer C. The client’s history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn’t be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce 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+ 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. 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? 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. 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 client with a spinal cord injury — particularly during the course of recovery — but don’t take precedence over a diagnosis of Ineffective breathing pattern. 21. A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department 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+ with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? a. Diencephalon b. Medulla c. Midbrain d. Cortex Answer C. Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity. 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+ 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. 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 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+ 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. 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 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+ 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+ Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea. Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. 27. A 70-year-old alcoholic patient with acute lethargy, 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. 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. 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 NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ A: Although blood urea nitrogen may be used to monitor volume status, it also is affected by the hypermetabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. B: Daily weight measures overall volume status, not just NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+ C. During initial fluid resuscitation, urine output helps guide therapy. 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+ D: Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status. 30. What is the total amount of fluid (in the first 24 hours) that will need to be administered to a 70kg man with a burn injury that covers 50% of his body surface area? A. 2800 mL B. 7000 mL C. 14 L D. 28 L C. 4 × 70 kg × 50 = 14,000 mL or 14 liters. 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+ 31. Which of the following is an essential nursing action for a patient who has circumferential full thickness burns on an extremity? 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 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: 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: 31-4 Question 12 Type: MCSA The nurse has adequately managed a patient’s airway, breathing, and circulation. What is the next nursing action? 1. Assess level of consciousness. 2. Administer prophylactic tetanus toxoid as prescribed. 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. Auscultate heart sounds. 4. Assess the chest for paradoxical movements. Correct Answer: 1 Rationale 1: The nurse should assess the patient's neurological status or level of consciousness as the next step. Rationale 2: Administering prophylactic tetanus toxoid and transferring the patient should happen after the assessment is complete. Rationale 3: Auscultation of heart sounds is part of the secondary survey, which is done after the primary survey. The primary survey is not yet complete. 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. Turn the patient to assess for injuries to the back. 5. Prepare to insert a chest tube. Correct Answer: 1,2 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 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+ 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+ Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-6 Question 19 Type: MCSA The nurse is caring for a patient who sustained a lacerated spleen from a motorcycle accident. Which complication is this patient most prone to experience because of the trauma? 1. Acute renal failure 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+ 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 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+ blood loss, but is more common if injuries to the abdomen exist. Global Rationale: 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? 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: 15-1 Question 3 Type: MCSA The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow? 1. Oversedation 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. Hypothermia 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. 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: 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. 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: An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-2 Question 5 Type: MCSA A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional 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+ intervention? 1. 12 mm Hg 2. 22 mm Hg 3. 25 mm Hg 4. 30 mm Hg Correct Answer: 1 Rationale 1: The normal intracranial pressure ranges from 0 to 15 mm Hg. Rationale 2: This pressure exceeds normal. Rationale 3: This pressure exceeds normal. Rationale 4: This pressure exceeds normal. 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? 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. The patient’s pupil size is increased. 3. The patient’s blood pressure has increased. 4. The patient exhibits decorticate posturing when stimulated. Correct Answer: 1 Rationale 1: The level of consciousness is the most important indicator of neurological function in the high-acuity patient. Rationale 2: Pupillary changes do occur with neurological damage but are not the earliest signs. Rationale 3: Changes in vital sign can indicate neurological damage, but are not the earliest signs. Rationale 4: Posturing is an important finding associated with neurologic damage, 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+ but is not the earliest sign. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 9 Type: MCSA A nurse is monitoring a patient’s Glasgow Coma Scale (GSC). At which point would the nurse document that the patient is comatose? 1. 11 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. 15 3. 7 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+ if decorticate or decerebrate posturing is present. Rationale 4: Administering sedation is not indicated at this time as assessment is continuing. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 1 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+ The nurse is providing community education regarding stroke. Which information should be included? 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. Stroke is caused by interruption of blood flow to the brain. 2. Stroke is the third-leading cause of death in the United States. 3. Stroke usually occurs simultaneously with myocardial infarction. 4. Rapid recognition of stroke symptoms can help decrease poor outcomes. 5. Stroke causes neurological defects. Correct Answer: 1,2,4,5 Rationale 1: Stroke occurs when a localized area of the brain is not receiving 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. 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: 17-1 Question 3 Type: MCSA When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor? 1. Hypertension 2. Use of anticoagulants 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. History of atherosclerosis of cerebral arteries 4. Atrial fibrillation Correct Answer: 4 Rationale 1: Hypertension is more likely associated with thrombotic stroke. Rationale 2: Use of anticoagulants and hypertension together are associated with hemorrhagic cerebral vascular accidents. Rationale 3: Atherosclerosis of cerebral arteries is associated with ischemic stroke. Rationale 4: Atrial fibrillation, in addition to endocarditis, rheumatic heart disease, and recent myocardial infarction, are the most common causes of embolic cerebral vascular accidents. 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. Transferring the patient for rehabilitation as soon as medically stable 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. 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: 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+ 1. CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain. 2. The CT scan will evaluate how much brain swelling is associated with this stroke. 3. The CT scan will pinpoint the exact area of the brain affected by the stroke. 4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke. Correct Answer: 4 Rationale 1: A CT alone will not determine the effectiveness of cerebral circulation. Rationale 2: CT scans cannot determine the extent of brain swelling. Rationale 3: CT scans cannot pinpoint the exact area of the brain affected by stroke, but can help to establish the anatomical region in which the stroke occurred. 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: 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 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+ Learning Outcome: 17-6 Question 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 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: 18-3 Question 2 Type: MCSA The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon? 1. Urine output has dropped from 100 mL each hour to 60 mL per hour. 2. The patient’s hand grasps are weak bilaterally. 3. Fine crackles can be auscultated in the lung bases bilaterally. 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. The pupil on the side of the injury has become fixed and dilated. 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 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+ 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. 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? NR 340 EXAM 3 QUESTIONS & ANSWERS ALL ANSWERS 100% CORRECT /VERIFIED BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2022 GRADED A+