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MS3 EXAM 1 QUESTIONS AND ANSWERS
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MS3 EXAM 1 QUESTIONS AND ANSWERS
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MS3 EXAM 1 QUESTIONS AND ANSWERSA 45 year old patient has just been admitted into the ER after a MVC. What is the
nurses priority intervention?
A. complete a glasgow coma scale assessment
B. ask the patient if they have insurance
C. obtain and EKG on the patient
D. Check that the patient has an airway - Answers- D
ABCs, airway is priority. pts with a head injury are at risk for hypoxia and respiratory
failure.
What are interventions for preventing increased ICP in a TBI patient? SATA
A. maintain ICP > 20
B. raise the HOB (head of bed) >30 degrees
C. start ordered IV mannitol
D. suction the patient q5 minutes
E. give patient prescribed miralax - Answers- B,C,E
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. - Answers- A
These manifestations indicate Cushing's syndrome, a potentially life-threatening
increase in intracranial pressure (ICP), which is an emergency. Immediate medical
attention is necessary, so the nurse notifies the provider or the Rapid Response Team.
Increasing fluids would increase the ICP. The client does not need a breathing treatment
or pain medication.
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the
hand-off report, which client should the nurse see first?
a. Client with a Glasgow Coma Scale score that was 10 and is now is 8
b. Client with a Glasgow Coma Scale score that was 9 and is now is 12
c. Client with a moderate brain injury who is amnesic for the event
d. Client who is requesting pain medication for a headache - Answers- A
A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the
nurse needs to see this client first. An improvement in the score is a good sign. Amnesia
is an expected finding with brain injuries, so this client is lower priority. The client
requesting pain medication should be seen after the one with the declining Glasgow
Coma Scale score
,A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The
client's spouse is very frustrated, stating that the client's personality has changed and
the situation is intolerable. What action by the nurse is best?
a. Explain that personality changes are common following brain injuries.
b. Ask the client why he or she is acting out and behaving differently.
c. Refer the client and spouse to a head injury support group.
d. Tell the spouse this is expected and he or she will have to learn to cope. - Answers-
A
Personality and behavior often change permanently after head injury. The nurse should
explain this to the spouse. Asking the client about his or her behavior isn't useful
because the client probably cannot help it. A referral might be a good idea, but the nurse
needs to do something in addition to just referring the couple. Telling the spouse to learn
to cope belittles the spouse's concerns and feelings.
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." - Answers- A
phenytoin is given in this circumstance to prevent seizures that can be caused by the
abcess
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 - Answers- C
ICP should be between 10-15mmHg. suctioning raises ICP and should be done only in
emergencies.
mannitol is a diuretic that decreases ICP. miralax is a stool softener that helps prevent
bowel strain that can increase ICP.
Which TBI patient needs immediate intervention from the nurse?
A. A patient who was speaking a few minutes ago but now is not speaking and has a
unreactive R pupil
B. A patient who is sleeping with HOB <30
C. A patient who is screaming at the nurses to get him something for his pain that is
10/10
, D. A patient who needs to have a bowel movement and is asking for a bedpan -
Answers- A
this patient is the most critical. A change in LOC, change in pupil reaction, breathing
pattern changes, hemodynamic instability, and drooping eyelids are all sings of danger
in a TBI patient. The RRT team should be called immediately.
Which of the following are signs of Cushing's triad? SATA
A. BP 220/82
B. HR 55
C. widened pulse pressure
D. HR 110 - Answers- A,B,C
cushing's triad: hypertension, bradycardia, and a widened pulse pressure
The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at
high risk of acquiring an infection. Communication and nutrition are not priorities
compared with preventing a brain infection. The client has a definite risk for a skin
breakdown, but it is not the immediate danger a brain infection would be.
The nurse is assessing a client with a neurologic health problem and discovers a
change in level of consciousness from alert to lethargic. What is the nurse's best action?
A. Perform a complete neurologic assessment
B. Assess the cranial nerve functions.
C. Contact the Rapid Response Team.
D. Reassess the client in 30 minutes. - Answers- C
A change in level of consciousness and orientation is the earliest and most reliable
indication that central neurologic function has declined. If a decline occurs, contact the
Rapid Response Team or health care provider immediately. The nurse should also
perform a focused assessment to determine if there are any other changes.
A TBI patient is complaining of severe pain 8/10 and is restless. What medication
should the nurse administer?
A. mannitol
B. fentanyl
C. phenobarbital
D. phenytoin - Answers- B
fentanyl is an opioid medication for pain relief and agitation. It also has fewer effects on
the HR and BP.
A TBI patient is on a ventilator and begins to fight the vent and appears restless and
anxious. What medication is best to give to settle the patient?
A. morphine
B. tylenol
C. phenytoin
D.propofol - Answers- D
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