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NUR 257 ( LATEST 2024 / 2025 ) FINAL 2 | PASSED | A+ RATED GUIDE | NEW FULL EXAM
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NUR 257 ( LATEST 2024 / 2025 ) FINAL 2 | PASSED | A+ RATED GUIDE | NEW FULL EXAM
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NUR 257 Final 21. A patient is being admitted to the neurologic ICU following an acute head injury that has
resulted in cerebral edema. When planning this patient's care, the nurse would expect to
administer what priority medication?
A) Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix)
C) Mannitol (Osmitrol)
D) Spirolactone (Aldactone)
Answer
C
2. The nurse is providing care for a patient who is unconscious. What nursing intervention takes
highest priority?
A) Maintaining accurate records of intake and output
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control
Answer
B
3. The nurse is caring for a patient in the ICU who has a brain stem herniation and who is
exhibiting an altered level of consciousness. Monitoring reveals that the patient's mean arterial
pressure (MAP) is 60 mm Hg with an intracra- nial pressure (ICP) reading of 5 mm Hg. What is
the nurse's most appropriate action?
A) Position the patient in the high Fowler's position as tolerated.
B) Administer osmotic diuretics as ordered.
C) Participate in interventions to increase cerebral perfusion pressure.
,D) Prepare the patient for craniotomy
Answer
C
4. The nurse is caring for a patient who is postoperative following a cranioto- my. When
writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid
restriction and osmotic diuretic use." What would be an appropriate intervention for this
diagnosis?
A) Change the patient's position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values.
Answer
B
5. A patient with a documented history of seizure disorder experiences a generalized seizure.
What nursing action is most appropriate?
A) Restrain the patient to prevent injury.
B) Open the patient's jaws to insert an oral airway.
C) Place patient in high Fowler's position.
D) Loosen the patient's restrictive clothing.
Answer
D
6. A patient who has been on long-term phenytoin (Dilantin) therapy is admit- ted to the unit.
In light of the adverse of effects of this medication, the nurse should prioritize which of the
,following in the patient's plan of care?
A) Monitoring of pulse oximetry
B) Administration of a low-protein diet
C) Administration of thorough oral hygiene
D) Fluid restriction as ordered
Answer
C
7. A nurse is admitting a patient with a severe migraine headache and a history of acute
coronary syndrome. What migraine medication would the nurse question for this patient?
A) Rizatriptan (Maxalt)
B) Naratriptan (Amerge)
C) Sumatriptan succinate (Imitrex)
D) Zolmitriptan (Zomig)
Answer
C
8. The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a
nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome
that the nurse would document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses.
Answer
D
, 9. A patient exhibiting an altered level of consciousness (LOC) due to
blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury
is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the
results of what diagnostic tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination
Answer
B
10. While completing a health history on a patient who has recently experienced a seizure,
the nurse would assess for what characteristic associated with the postictal state?
A) Epileptic cry
B) Confusion
C) Urinary incontinence
D) Body rigidity
Answer
B
11. A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most
recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The
nurse would be correct in suspecting the presence of what complication?
A) Encephalitis
B) CSF leak
C) Meningitis
D) Catheter occlusion
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