NUR 445 EXAM 3 NEWEST 2025 ACTUAL EXAM

• | P a g e

NUR 445 EXAM 3 NEWEST 2025 ACTUAL EXAM

COMPLETE 80 QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED ANSWERS)

|ALREADY GRADED A+ /ARIZONA COLLEGE OF

NURSING

The nurse is caring for a client who has right-sided weakness and Broca's aphasia following a stroke that occurred 36 hours ago. Which assessment instruction should the nurse use with this client?

• "Tell me what you were doing immediately before your

illness."

• "Can you see anything at all out of your bad eye?"
• "Lift your unaffected arm up as much as you can."
• "Describe the sensations you have in your good leg." -

ANSWER-Answer: 3

A client is admitted after being struck in the right side of the head with a baseball bat. An MRI shows the presence of focal injury and DAI. Which mechanism of injury is likely to have occurred?

• Acceleration 1 / 4

• | P a g e

• Deceleration
• Rotational

4. Penetrating - ANSWER-Answer: 3

A client was admitted to the emergency department after a traumatic brain injury. Current assessment included a decrease in Glasgow Coma Scale by one point and development of a fixed and dilated pupil. What should the nurse do first?

• Plan to reassess the client in 15 minutes.
• Call the healthcare provider immediately.
• Continue to prepare the client for an ordered CT scan.

4. Inform the family of the status changes. - ANSWER-Answer:

2

A client fell on an icy sidewalk a week ago, striking the head on the curb. The CT scan reveals an accumulation of blood between the dura and the arachnoid covering of the brain. The nurse would prepare to care for a client with which diagnosis?

• Subdural hematoma
• Epidural hematoma
• Subarachnoid hematoma
• Intracerebral hematoma - ANSWER-Answer: 1 2 / 4

• | P a g e

A client sustained a brain injury when struck by a falling tree limb. Upon admission to the emergency department (ED) the client's Glasgow Coma Score was 10. What interventions will the ED nurse expect to manage? (Select all that apply.)

• Explanation of brain injury surveillance as discharge

instructions

• Skull x-rays
• CT scan
• Hospital admission
• Placement of an indwelling urinary catheter - ANSWER-

Answer: 2, 3, 4

A client has an expanding epidural hematoma and is taken to the OR to have it evacuated. The client returns to the ICU ventilated and with an intraventricular catheter in place. According to Brain Trauma Foundation Guidelines, what is the minimal cerebral perfusion pressure (CPP) desired to reduce secondary injury in this client?

• 50 mm Hg
• 60 mm Hg
• 70 mm Hg

4. 80 mm Hg - ANSWER-Answer: 2 3 / 4

• | P a g e

A client who sustained a traumatic brain injury develops abrupt hypertension, bradycardia, and an irregular breathing pattern.The nurse immediately collaborates with the healthcare provider for which reason?

• The client needs additional pain medication.
• Anxiety is building that may cause additional problems.
• Herniation may be occurring.

4. Brain death is occurring. - ANSWER-Answer: 3

A client in the ICU who sustained a traumatic brain injury is being mechanically ventilated. Which nursing interventions should be implemented to manage increased intracranial pressure? (Select all that apply.)

• Position the client supine with head of bed flat.
• Preoxygenate the client if suctioning is needed.
• Keep the client's neck in a neutral position.
• Elevate the head of the bed by 30 degrees.

5. Provide pain medication. - ANSWER-Answer: 2, 3, 4, 5

The nurse has attempted to control a client's increased intracranial pressure with level one interventions, but the

• / 4