Tiêu đề WORKBOOK - ERDN (KEY) ✅

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
49. Based on the client’s vital signs, she appears to be in shock. Which types of shock are you most concerned about this client? A. Cardiogenic Shock B. Hypovolemic Shock C. Neurogenic Shock D. Septic Shock E. Anaphylactic Shock A. a and b B. a and c C. b and c D. c and d 50. The nurse is aware that the drainage from the ear and nose indicates: A. Contusion B. Concussion C. Nose fracture D. Basilar fracture 51. Grey Sloan Hospital responds to a landslide. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? A. Provide water and healthy snacks for energy throughout the event. B. Schedule 16-hour shifts to allow for greater rest between shifts. C. Encourage counseling upon deactivation of the emergency response plan. D. Assign staff to different roles and units within the medical facility. 52. There was an explosion in a nearby rubber factory with 400 workers. Grey Sloan Hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? I. Paramedic: decides the number, acuity, and resource needs of clients II. Hospital incident commander: assumes overall leadership for implementing the emergency plan III. Public information officer: provides advanced life support during transportation to the hospital IV. Triage officer: rapidly evaluates each client to determine priorities for treatment V. Medical command physician: serves as a liaison between the health care facility and the media A. II,IV B. I,II C. I,II,III D. I,II,III,IV 53. Grey Sloan Memorial Hospital is the nearest trauma center from a multiple vehicular collision in a highway. Which clients should Nurse Jane identify as appropriate for discharge or transfer to another facility? (SATA) I. Mang Tomas, an adult in the medical decision unit for evaluation of chest pain II. Elie who had open reduction and internal fixation of a femur fracture 3 days ago III. Martin admitted last night with community-acquired pneumonia IV. Infant who has a fever of unknown origin V. Client on the medical unit for wound care A. I,II B. II,V C. I,III D. IV,V 54. Nurse Felisa triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? I. A 35-year-old female with severe chest pain: red tag II. A 42-year-old male with full-thickness body burns: green tag III. A 55-year-old female with a scalp laceration: black tag IV. A 60-year-old male with an open fracture with distal pulses: yellow tag V. An 88-year-old male with shortness of breath and chest bruises: green tag A. III,IV B. II,III C. I,IV D. I,II,III 55. Nurse Veronica is the triage nurse tonight. The nurse identifies the clients with which injuries with yellow tags? (SATA) I. Partial-thickness burns covering both legs II. Open fractures of both legs with absent pedal pulses III. Neck injury and numbness of both legs IV. Small pieces of shrapnel embedded in both eyes V. Head injury and difficult to arouse VI. Bruising and pain in the right lower abdomen A. I,III,VI B. II,III,IV C. I,III,IV,V D. I,III,IV,VI 56. Nurse Susan is the charge nurse and has observed that for the same week that the landslide happened, staff conflicts increaseD. Which action should the nurse take? A. Organize a pizza party for each shift. B. Remind the staff of the facility's sick-leave policy. C. Arrange for critical incident stress debriefing. D. Talk individually with staff members. 57. Heidi is a single mother of 5 children. Along with her children, they are in the emergency department due to a shooting incident in the community. Which intervention should the nurse complete first? A. Provide a calm location for the family to cope and discuss needs. B. Call the hospital chaplain to stay with the family and pray for the deceased. C. Do not allow visiting of the victims until the bodies are prepared. D. Provide privacy for law enforcement to interview the family. 58. Brgy. Sto. Cristo has been struck by an intensity 5.6 earthquake. After Grey Sloan Memorial Hospital emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? A. Are you sure no more victims are coming into the ED? B. Do all areas of the hospital have the supplies and personnel they need? C. Have all ED staff had the chance to eat and rest recently? D. Does the Chief Medical Officer agree this disaster is under control? 59. Mang Bert is a survivor in an earthquake that hit their barrio. He asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? A. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. B. Not everyone will survive a disaster, so it is best to identify those people early and move on. C. In a disaster, extensive resources are not used for one person at the expense of many others. D. With black tags, volunteers can identify those who are dying and can give them comfort care. 60. Nurse Clara is caring for a client whose husband died in a recent mass casualty accident. The client says, "I cant believe that my husband is gone and I am left to raise my children all by myself." How should the nurse respond? A. Please accept my sympathies for your loss. B. I can call the hospital chaplain if you wish. C. You sound anxious about being a single parent. D. At least your children still have you in their lives. TOP RANK REVIEW ACADEMY, INC. Page 4 | 7