Blog

20. After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a client with a traumatic head injury has increased from 14 to 17 mmHg. Which action should the nurse take first?

31. A client is being evaluated for a possible spinal cord injury due to a fall. Which finding by the nurse requires the most immediate action?

55. The nurse is admitting a client with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the client’s nose. Which admission order should the nurse question?

38.  Health promotion for a client with spinal cord injury include implementation of which measure? Counseling Education Encourage seat belts Encourage helmets Identify those that are at high-risk  

48. The nurse is caring for a client who has a head injury and fractured right arm after being assaulted. He is examined by the primary health care provider (PHCP) and the CT scan identifies an acute subdural hematoma. Which assessment information requires rapid action by the nurse?

50. While admitting a 42-yr-old client with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

59.  The nurse is caring for a client who was diagnosed with an aneurysm measuring 6.5 cm.  with a graft recently placed.  The client is being admitted now to determine the patency of the graft.  The nurse would assess for which findings indicating patency?

32.  A client has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Sequard syndrome.  Which nursing action should be included in the plan of care?

8. A nurse is caring for a client who has burns of the ears, head, neck, and right arm.  The nurse should place the client in which position to decrease risk of contractures?

23. A client who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the client’s skin color is bright red. Which action would be of highest priority for the nurse to implement?