The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? - Answer-Diminished breath sounds
Thoracentesis causing pneumothorax (Signs and symptoms of pneumothorax) - Answer-Trach...
Capstone Exam 3 Questions with
Correct Answers
The emergency department nurse is assessing a client who has sustained a blunt injury
to the chest wall. Which finding indicates the presence of a pneumothorax in this client?
- Answer-Diminished breath sounds
Thoracentesis causing pneumothorax (Signs and symptoms of pneumothorax) -
Answer-Tracheal deviation, Sensation of air hunger, Cyanosis of oral mucous
membranes
Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does
the nurse expect to be prescribed before the administration of this medication - Answer-
Liver function tests.
The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing
treatment. Which report from the client should the nurse note as an expected side effect
of this combination - Answer-I feel like my heart is racing.
The nurse is assessing the motor and sensory function of an unconscious client who
sustained a head injury. The nurse should use which technique to test the client's
peripheral response to pain? - Answer-Nail Bed pressure
A nurse is teaching family members of a client with a concussion about the early signs
of increased cranial pressure ICP. Which of the following would the nurse cite as early
signs of ICP? - Answer-headache and vomiting
The nurse is monitoring a 3-year-old child for signs and symptoms of increased
intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which
early sign or symptom of increased ICP? - Answer-Vomiting
What is one of the earliest signs of increased intracranial pressure ICP? - Answer-
decreased level of consciousness (LOC)
A mother arrives at the emergency department with her 5-year-old chills and states that
the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's
airway status and assesses the child for early and late signs of ICP.Which is the late
sign? - Answer-Bradycardia
The nurse is reviewing the record of a child with ICP and notes that the child has
exhibited signs of decerebrate posturing. On assessment of the child the nurse expects
to note which characteristic of this type posturing? - Answer-Rigid extension and
pronation of the arms and legs
, A client recovering from a head injury is participating in care. The nurse determines that
the client understands measures to prevent elevations in ICP if the nurse observes the
client doing which activity? - Answer-Exhaling during repositioning
The nurse is caring for the client with ICP as a result of a head injury/ the nurse would
note which trend in VS if the intracranial pressure is rising? - Answer-Increasing temp,
decreasing pulse, decreasing respirations, increasing blood pressure
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most
appropriate action by the nurse? - Answer-Continuing to observe the seizure
The nurse is creating a plan of care for a child who is at risk for seizures. Which
interventions apply if the child has a seizure? - Answer-Time the seizure, Stay with the
child, Move the furniture away from the child
The nurse is caring for a client who begins to experience seizure activity while in bed.
Which actions should the nurse take? (SATA) - Answer-Loosening restrictive clothing,
Removing the pillow and raising padded side rails, Positioning the client to the side, if
possible with the head flexed forward
The nurse is instituting seizure precautions for a client who is being admitted from the
emergency department. Which measures should the nurse include in planning for the
client's safety? (SATA) - Answer-Padding the side rails of the bed, Placing an airway at
the bedside, Placing oxygen and suction equipment at the bedside, and Flushing the
intravenous catheter to ensure that the site is patent
The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan
of care the nurse identifies seizure precautions and documents which items need to be
placed at the child's bedside? - Answer-Suctioning equipment and oxygen
A nurse is providing discharge teaching to parents whose infant had a
ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the
following statements by the parents indicates an understanding of the teaching? -
Answer-"We will notify the doctor right away if he has a fever."
Important to communicate to the surgeon after ventriculoperitoneal shunt is placed?3-
year-old returned ped unit - Answer-The right pupil is 1mm larger than the left pupil
A 27-year-old patient is hospitalized with new onset of Guillain-Barre syndrome. The
most essential assessment for the nurse to - Answer-carry out is observing respiratory
rate and effort.
The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The
client has complaints of inability to move both legs and reports a tingling sensation
above the waistline. Knowing the complications of the disorder the nurse should bring
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