Tiêu đề WORKBOOK - ERDN (SC) ✅

34. When intracranial pressure increases, which of the following nursing diagnosis is appropriate? A. Risk for ineffective breathing pattern B. Disturbed sensory perception C. Risk for cardiac dysfunction D. Ineffective airway clearance 35. Which of the following interventions can the nurse include in the plan of care for Kevin to control intracranial pressure? 1. Maintain his head and neck in neutral alignment 2. Initiate measures to enhance valsalva maneuver 3. Administer O2 to maintain paO2 >90 mmHg 4. Elevate head of the bed as prescribed A. 1 and 2 B. All except 2 C. 3 and 4 D. All of the above Situation: Helen, a Pediatric Intensive Care Unit staff nurse, is assigned to a 4-year-old female unconscious patient due to an acute head injury sustained from a vehicular accident. 36. Helen identifies which of the following nursing diagnosis to be of highest priority? A. Risk for injury related to increased intracranial pressure B. Disturbed sensory perception relation to central nervous system impairment C. Risk for aspiration related to impaired motor functions. D. Ineffective airway clearance related to depressed sensorium 37. When interpreting the patient’s degree of depressed coma, the pediatric Glasgow Coma Scale is used. Which of the following is not included in the three-part assessment of the scale? A. Motor responses B. Response to auditory and verbal stimuli C. Pupils size and reaction D. Eye opening 38. During assessment, the nurse observes absence of doll’s eye movement. Which of the following is the correct interpretation of this observation? A. Ruptured aneurysm B. Meningeal inflammation C. Brainstem injury D. Subdural hematoma 39. Due to hypothalamic dysfunction, a syndrome of inappropriate antidiuretic hormone develops. Which of the following manifestations should the nurse watch closely? A. Increased urine output, decreased urine specific gravity, decreased serum sodium B. Increased urine output, increased urine specific gravity, increased serum sodium C. Decreased urine output, decreased urine specific gravity, increased serum sodium D. Decreased urine output, increased urine specific gravity, decreased serum sodium 40. During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for: A. presence of a neck injury B. neurological status with the Glasgow Coma Scale C. cerebrospinal fluid leakage from ears or nose D. patency of airway Situation: Nurse Girlie witnesses a vehicular accident near the hospital where she works. She decides to get involved and help the victims of the accident 41. Her priority nursing action would be to: A. Assess damage to property B. Assist in the police investigation since she is a witness C. Report the incident immediately to the local police authorities D. Assess the extent of injuries incurred by the victims of the accident 42. Priority attention should be given to which of these clients? A. Linda who shows severe anxiety due to trauma of the accident B. Ryan who has chest injury, is pale and with difficulty breathing C. Noel who has lacerations on the arms with mild bleeding D. Andy whose left ankle swelled and has some abrasions 43. The nurse applies dressing on the bleeding site. This intervention is done to: A. Reduce the need to change dressing frequently B. Allow the pus to surface faster C. Protect the wound from microorganisms in the air D. Promote hemostasis 44. After the treatment, the client is sent home and asked to come back for follow-up care. Your responsibilities when the client is to be discharged include the following EXCEPT: A. Encouraging the client to go to the outpatient clinic for follow up care B. Accurate recording of treatment done and instructions given to client C. Instructing the client to see you after discharge for further assistance D. Providing instructions regarding wound care 45. You are assigned to care for four (4) patients. Which of the following patients should you give first priority? A. Grace, who is terminally ill with breast cancer. B. Emy, who was previously lucid but is now unarousable. C. Aris, who is newly admitted and is scheduled for an executive check-up. D. Claire, who has cholelithiasis and is for operation on call 46. A young client who was hit by a car was fortunate because the level of injury did not interrupt his respiratory function. The cord segment involved with maintain respiratory function are: A. Thoracic level 5 and 6 B. Thoracic level 2 and 3 C. Cervical level 7 and 8 D. Cervical level 3 and 4 47. A quadriplegic client tell the nurse that he believes he is experiencing an episode of autonomic hyperreflexia (dysreflexia). The first nursing intervention if to: A. Ask him what he thinks has precipitated this episode B. Assess his blood pressure and pulse C. Elevate his head as high as possible D. Assist him in emptying his bladder Situation: Ms. Alcantara’s blood pressure is 70/30 mmHg, she is in a sinus tachycardia with a rate of 40 and her respiratory rate is 6 breaths per minute. Her respirations are irregular and she has 20 second periods of apnea. Assessment continues and the nurse noted large occipital laceration and protruded bone on her left leg. 48. When performing an assessment the nurse identifies a clear, watery drainage oozing from the client’s ear. Before notifying the physician, the best nursing action to take would be: A. Testing the fluid for glucose and applying sterile dressing. B. Positioning the client so that the unaffected ear is dependent. C. Covering the area with sterile gauze and applying slight pressure. D. Cleaning the outer ear with normal saline and inserting a clean cotton ball. TOP RANK REVIEW ACADEMY, INC. Page 3 | 7