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NUR 336 ICR Final Exam Practice Questions With Complete Solutions
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NUR 336 ICR Final Exam Practice Questions With Complete Solutions
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NUR 336 ICR Final Exam Practice Questions WithComplete Solutions
A 5-year-old girl sustained a concussion when she fell out of a
tree. In preparation for discharge, the nurse is discussing home
care with her mother. Which statement made by the mother
indicates a correct understanding of the teaching?
a. I should expect my child to have a few episodes of vomiting.
b. If I notice sleep disturbances, I should contact the physician
immediately.
c. I should expect my child to have some behavioral changes
after the accident.
d. If I notice diplopia, I will have my child rest for 1 hour.
Correct Answers C. I should expect my child to have some
behavioral changes after the accident
A child has been seizure-free for 2 years. A father asks the nurse
how much longer the child will need to take the antiseizure
medications. The nurse includes which intervention in the
response?
a. Medications can be discontinued at this time.
b. The child will need to take the drugs for 5 years after the last
seizure.
c. A stepwise approach will be used to reduce the dosage
gradually.
d. Seizure disorders are a lifelong problem. Medications cannot
be discontinued. Correct Answers C. A stepwise approach will
be used to reduce the dosage gradually
,A child is unconscious after a motor vehicle accident. The
watery discharge from the nose tests positive for glucose. The
nurse should recognize that this suggests:
a. Diabetic coma.
c. Upper respiratory tract infection.
b. Brainstem injury.
d. Leaking of cerebrospinal fluid (CSF). Correct Answers D.
Leaking of cerebrospinal fluid (CSF)
A client experiences impaired swallowing after a stroke and has
worked with speech-language pathology on eating. What
nursing assessment best indicates that a priority goal for this
problem has been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week Correct Answers C. Has clear
lung sounds on auscultation
A client had an embolectomy for an arteriovenous malformation
(AVM). The client is now reporting a severe headache and has
vomited. What action by the nurse takes priority?
a. Administer pain medication.
b. Assess the clients vital signs.
c. Notify the Rapid Response Team.
d. Raise the head of the bed. Correct Answers C. Notify the
rapid response team
A client had an embolic stroke and is having an echocardiogram.
When the client asks why the provider ordered a test on my
heart, how should the nurse respond?
,a. Most of these types of blood clots come from the heart.
b. Some of the blood clots may have gone to your heart too.
c. We need to see if your heart is strong enough for therapy.
d. Your heart may have been damaged in the stroke too. Correct
Answers A. Most of these types of blood clots come from the
heart
A client has a brain abscess and is receiving phenytoin
(Dilantin). The spouse questions the use of the drug, saying the
client does not have a seizure disorder. What response by the
nurse is best?
a. Increased pressure from the abscess can cause seizures.
b. Preventing febrile seizures with an abscess is important.
c. Seizures always occur in clients with brain abscesses.
d. This drug is used to sedate the client with an abscess. Correct
Answers A. Increased pressure from the abcess can cause
seizures
A client has a small-bore feeding tube (Dobhoff tube) inserted
for continuous enteral feedings while recovering from a
traumatic brain injury. What actions should the nurse include in
the clients care? (Select all that apply.)
a. Assess tube placement per agency policy.
b. Keep the head of the bed elevated at least 30 degrees.
c. Listen to lung sounds at least every 4 hours.
d. Run continuous feedings on a feeding pump.
e. Use blue dye to determine proper placement. Correct
Answers A. Assess tube placement per agency policy
B. Keep the head of the bed elevated at least 30 degrees
C. Listen to lung sounds at least every 4 hours
D. Run continuous feedings on a feeding pump
, A client has a traumatic brain injury and a positive halo sign.
The client is in the intensive care unit, sedated and on a
ventilator, and is in critical but stable condition. What
collaborative problem takes priority at this time?
a. Inability to communicate
b. Nutritional deficit
c. Risk for acquiring an infection
d. Risk for skin breakdown Correct Answers C. Risk for
acquiring an infection
A client has a traumatic brain injury. The nurse assesses the
following: pulse change from 82 to 60 beats/min, pulse pressure
increase from 26 to 40 mm Hg, and respiratory irregularities.
What action by the nurse takes priority?
a. Call the provider or Rapid Response Team.
b. Increase the rate of the IV fluid administration.
c. Notify respiratory therapy for a breathing treatment.
d. Prepare to give IV pain medication. Correct Answers A. Call
the provider or Rapid response team
A client has an intraventricular catheter. What action by the
nurse takes priority?
a. Document intracranial pressure readings.
b. Perform hand hygiene before client care.
c. Measure intracranial pressure per hospital policy.
d. Teach the client and family about the device. Correct
Answers B. Perform hand hygiene before client care
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