Unit Exam 3 Capstone Study Guide with Answers (98 Solved Questions)
Unit Exam 3 Capstone Study Guide with Answers gives you insight into exam patterns with actual previous tests.
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UNIT EXAM 3 STUDY GUIDE
Trauma – (Client in trauma has absent breath sounds what this mean?
Pneumothorax)
The emergency department nurse is assessing a client who has sustained a blunt
injury to the chest wall.
Which finding indicates the presence of a pneumothorax in this client?
-Diminished breath sounds
Thoracentesis causing pneumothorax (Signs and symptoms of pneumothorax):
-Tracheal deviation
-Sensation of air hunger
-Cyanosis of oral mucous membranes
Zafirlukast
Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test
does the nurse expect to
be prescribed before the administration of this medication?
Liver function tests.
Albuterol/Ipratropium
The nurse is caring for a client receiving an albuterol/ipratropium nebulized
breathing treatment. Which
report from the client should the nurse note as an expected side effect of this
combination?
I feel like my heart is racing.
Head Injury (craniotomy: Head circumference (measure head)
The nurse is assessing the motor and sensory function of an unconscious client
who sustained a head injury. The nurse should use which technique to test the
client's peripheral response to pain?
Nail Bed pressure
Increased intracranial Pressure- early sign: headache (from Saunders book)
A nurse is teaching family members of a client with a concussion about the early
signs of increased cranial pressure, ICP. Which of the following would the nurse
cite as early signs of ICP?
headache and vomiting
The nurse is monitoring a 3-year-old child for signs and symptoms of increased
intracranial pressure
lOMoARcPSD|12950611
Trauma – (Client in trauma has absent breath sounds what this mean?
Pneumothorax)
The emergency department nurse is assessing a client who has sustained a blunt
injury to the chest wall.
Which finding indicates the presence of a pneumothorax in this client?
-Diminished breath sounds
Thoracentesis causing pneumothorax (Signs and symptoms of pneumothorax):
-Tracheal deviation
-Sensation of air hunger
-Cyanosis of oral mucous membranes
Zafirlukast
Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test
does the nurse expect to
be prescribed before the administration of this medication?
Liver function tests.
Albuterol/Ipratropium
The nurse is caring for a client receiving an albuterol/ipratropium nebulized
breathing treatment. Which
report from the client should the nurse note as an expected side effect of this
combination?
I feel like my heart is racing.
Head Injury (craniotomy: Head circumference (measure head)
The nurse is assessing the motor and sensory function of an unconscious client
who sustained a head injury. The nurse should use which technique to test the
client's peripheral response to pain?
Nail Bed pressure
Increased intracranial Pressure- early sign: headache (from Saunders book)
A nurse is teaching family members of a client with a concussion about the early
signs of increased cranial pressure, ICP. Which of the following would the nurse
cite as early signs of ICP?
headache and vomiting
The nurse is monitoring a 3-year-old child for signs and symptoms of increased
intracranial pressure
lOMoARcPSD|12950611
(ICP) after a craniotomy. The nurse plans to monitor for which early sign or
symptom of increased ICP?
Vomiting
What is one of the earliest signs of increased intracranial pressure ICP?
decreased level of consciousness (LOC)
A mother arrives at the emergency department with her 5-year-old chills and states
that the child fell off a
bunk bed. A head injury is suspected. The nurse checks the child's airway status
and assesses the child for
early and late signs of ICP.Which is the late sign?
Bradycardia
The nurse is reviewing the record of a child with ICP and notes that the
child has exhibited signs of decerebrate posturing. On assessment of the child,
the nurse expects to note which characteristic of this type posturing?
Rigid extension and pronation of the arms and legs
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in ICP if
the nurse observes the client doing which activity?
Exhaling during repositioning
1
The nurse is caring for the client with ICP as a result of a head injury/ the
nurse would note which trend in
VS if the intracranial pressure is rising?
Increasing temp, decreasing pulse, decreasing respirations, increasing blood
pressure
Seizure (Continue Monitoring when pt is experiencing a seizure turns
cyanotic)
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the
most appropriate action
by the nurse?
Continuing to observe the seizure
The nurse is creating a plan of care for a child who is at risk for seizures. Which
symptom of increased ICP?
Vomiting
What is one of the earliest signs of increased intracranial pressure ICP?
decreased level of consciousness (LOC)
A mother arrives at the emergency department with her 5-year-old chills and states
that the child fell off a
bunk bed. A head injury is suspected. The nurse checks the child's airway status
and assesses the child for
early and late signs of ICP.Which is the late sign?
Bradycardia
The nurse is reviewing the record of a child with ICP and notes that the
child has exhibited signs of decerebrate posturing. On assessment of the child,
the nurse expects to note which characteristic of this type posturing?
Rigid extension and pronation of the arms and legs
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in ICP if
the nurse observes the client doing which activity?
Exhaling during repositioning
1
The nurse is caring for the client with ICP as a result of a head injury/ the
nurse would note which trend in
VS if the intracranial pressure is rising?
Increasing temp, decreasing pulse, decreasing respirations, increasing blood
pressure
Seizure (Continue Monitoring when pt is experiencing a seizure turns
cyanotic)
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the
most appropriate action
by the nurse?
Continuing to observe the seizure
The nurse is creating a plan of care for a child who is at risk for seizures. Which
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