NUR 148 EXAM 3 - traumatic brain injury. Which assessment findin...

NUR 148 EXAM 3

• The nurse is preparing to conduct a focused neurologic assessment for a client who had a

traumatic brain injury. Which assessment finding is the immediate concern of the nurse?

• disorientation
• numbness in both arms
• decreased level of consciousness
• report of headache

Answer C

• The nurse is caring for a client following a cerebral angiography. Which assessment finding

will the nurse report immediately to the primary health care provider?

• discomfort at the injection site
• bleeding from the injection site
• fatigue and weakness
• mild headache

Answer B

• The nurse is caring for 76-year old client whose daughter reports has had memory loss.

Which nursing statement facilitates assessment of memory?

• "count backward from 100 by 7s"
• "tell me what this fable means to you."
• "describe how you came to the hospital today."
• "I will write a word down, and you copy it on this paper."

Answer C

• The nurse is caring for an older client who is usually alert and oriented. When the client

becomes suddenly confused, what is the priority nursing assessment?

• SpO2
• temperature
• drug reconcilliation 1 / 2

• laboratory electrolyte results

Answer A

• The nurse is caring for a 30-year-old client who experienced a frontal lobe infarction after a

motorcycle accident. What is the appropriate nursing intervention?

• enable the bed alarm safety alarm
• use a picture board to communicate
• place all items directly in front of the client
• teach to use a call light before getting out of bed

Answer A

• The nurse is caring for a client who is diagnosed with early-stage alzheimer's disease who

has periods of lucidity. What is the best principle for the nurse to use when communicating with this client?

• use validation therapy to prevent upsetting the client
• encourage pet therapy to prevent upsetting the client
• use aromatherapy and other integrative therapies to relax the client
• reorient the client frequently to foster reality

Answer D

• A client experiences seizures that is observed by the nurse. What will the nurse document in

the client's medical record? Select all that apply.

• time that seizure began and ended
• whether the seizure was preceded by an aura
• what the client does after the seizure
• how long it takes for the client to return to preseizure status
• the drugs that are administered during the seizure

Answer A, B, C, D

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