Download NUR 211 Final Exam with precise detailed answers and more Exams Nursing in PDF only on Docsity!
NUR || 211 || Final || Exam || with || precise || detailed || answers
A || nurse || caring || for || a || client || with || sickle || cell || disease || (SCD) || reviews || the || client's || laboratory || work. || Which || finding || should || the || nurse || report || to || the || provider? A. || Creatinine: || 2. B. || Hematocrit: || 30% C. || Sodium: || 147 D. || WBC: || 12,000 || - || ✔✔A. || Creatinine: || 2. An || elevated || creatinine || indicates || kidney || damage, || which || occurs || in || SCD. || A || hematocrit || level || of || 30% || is || an || expected || finding, || as || is || a || slightly || elevated || white || blood || cell || count. || A || sodium || of || 147, || although || slightly || high, || is || not || concerning A || client || hospitalized || with || sickle || cell || crisis || frequently || asks || for || opioid || pain || medications, || often || shortly || after || receiving || a || dose. || The || nurses || on || the || unit || believe || the || client || is || drug || seeking. || When || the || client || requests || pain || medication, || what || action || by || the || nurse || is || best? A. || Give || the || client || pain || medication || if || it || is || time || for || another || dose. B. || Instruct || the || client || not || to || request || pain || medication || too || early. C. || Request || the || provider || to || leave || a || prescription || for || a || placebo D. || Tell || the || client || it || is || too || early || to || have || more || pain || medication || - || ✔✔A. || Give || the || client || pain || medication || it || it || is || time || for || another || dose. Clients || with || sickle || cell || crisis || often || have || severe || pain || that || is || managed || with || up || to || 48 || hours || of || IV || opioid || analgesics. || Even || if || the || client || is || addicted || and || drug || seeking, || he || or || she || is || still || in || extreme || pain. || If || the || client || can || receive || another || doe || of || medication, || the || nurse || should || provide || it, || The || other || options || are || judgmental || and || do || not || address || the || client's || pain. || Giving || placebos || is || unethical. A || client || in || sickle || cell || crisis || is || dehydrated || and || in || the || emergency || department. || The || nurse || plans || to || start || an || IV. || Which || fluid || choice || is || best?
A. || 0.45% || normal || saline B. || 0.9% || normal || saline C. || Dextrose || 50% || (D50) D. || Lactated || Ringers || solution || - || ✔✔A. || 0.45% || normal || saline Because || clients || in || sickle || cell || crisis || are || often || dehydrated, || the || fluid || of || choice || is || a || hypotonic || solution || such || as || 0.45% || normal || saline. || ).9% || normal || saline || and || lactated || ringers || solution || are || isotonic. || D50 || is || hypertonic || and || not || used || for || hydration. A || client || presents || to || the || emergency || department || in || sickle || cell || crisis. || What || intervention || by || the || nurse || takes || priority? A. || Administer || oxygen B. || Apply || an || oximetry || probe C. || Give || pain || medication D. || Start || an || IV || line || - || ✔✔A. || Administer || oxygen All || actions || are || appropriate, || but || remembering || the || ABCs, || oxygen || would || come || first. || The || main || problem || in || a || sickle || cell || crisis || is || tissue || and || organ || hypoxia, || so || providing || oxygen || helps || halt || the || process. A || client || has || a || sickle || cell || crisis || with || extreme || lower || extremity || pain. || What || comfort || measure || does || the || nurse || delegate || to || the || UAP? A. || Apply || ice || packs || to || the || client's || legs B. || Elevate || the || clients || legs || on || pillows C. || Keep || the || lower || extremities || warms. D. || Place || elastic || bandage || wraps || on || the || client's || legs. || - || ✔✔C. || Keep || the || lower || extremities || warm
clients || with || SCD. || Hematocrit || and || hemoglobin || levels || are || normally || low || in || people || with || SCD. || The || potassium || level, || while || slightly || low, || is || not || worrisome || as || the || WBCs. A || nurse || working || with || clients || with || sickle || cell || disease || teaches || about || self-management || to || prevent || exacerbations || and || sickle || cell || crisis. || What || factors || should || clients || be || taught || to || avoid? || (Select || all || that || apply) A. || Dehydration B. || Exercise C. || Extreme || stress D. || High || altitudes E. || Pregnancy || - || ✔✔A,C,D,E Several || factors || cause || RBCs || to || sickle || in || SCD, || including || dehydration, || extreme || stress, || high || altitudes, || and || pregnancy. || Strenuous || exercise || can || also || cause || sickling, || but || not || unless || it || is || very || vigorous. The || nurse || is || teaching || a || client || who || has || sickle || cell || disease || and || was || admitted || for || splenomegaly || and || abdominal || pain. || Which || instruction || does || the || nurse || include || in || the || clients || discharge || teaching? A. || Avoid || drinking || large || amounts || of || fluids B. || Eat || six || small || meals || daily || instead || of || large || meals C. || Engage || in || aerobic || 3 || days || a || week D. || Receive || a || yearly || influenza || vaccination || - || ✔✔D. || Receive || a || yearly || influenza || vaccination Abdominal || pain || and || a || palpable || spleen || could || indicate || blood || trapped || in || the || spleen. || Over || time, || the || spleen || may || become || nonfunctional, || which || the || client || at || risk || for || infection. || An || annual || influenza || vaccination || helps || prevent || infection. || A || client || with || sickle || cell || disease || should || not || become || dehydrated || or || engage || in || strenuous || physical || activity || because || this || could || precipitate || a || crisis. || Eating || smaller || meals || has || no || impact || on || sickle || cell || disease || of || infection.
The || nurse || is || caring || for || a || client || during || a || sickle || cell || crisis. || Which || intervention || does || the || nurse || implement || for || the || client? A. || Administer || acetaminophen || as || needed B. || Administer || intravenous || fluids || to || keep || the || vein || open C. || Keep || the || room || temperature || at || 80F D. || Transfuse || red || blood || cells || (RBCs) || - || ✔✔C. || Keep || the || room || temperature || at || 80 || F Keeping || the || room || warm || can || be || used || as || a || complementary || therapy || to || relieve || the || pain || of || a || sickle || cell || crisis. || Cold || can || act || as || a || factor || in || causing || a || crisis. || Analgesia || is || an || important || prt || of || receiving || pain. || The || analgesia || routine || should || be || followed || on || an || around-the-clock || basis || and || should || consist || of || IV || opioids || for || severe || pain, || followed || by || treatment || with || oral || doses || of || opioids || of || NSAIDs. || High-volume || intravenous || fluids || be || administered || to || minimize || pain || during || sickle || cell || crisis. The || nurse || is || transfusing || red || blood || cells || to || a || client || who || has || sickle || cell || disease. || Which || laboratory || result || indicates || that || the || nurse || should || discontinue || the || transfusion? A. || Hematocrit: || 32% B. || Hemoglobin || 88% C. || Serum || iron || level: || 300 D. || WBC: || 12,000 || - || ✔✔C. || Serum || iron || level: || 300 Clients || with || sickle || cell || disease || are || anemic || but || are || not || iron || deficient. || Transfusions || are || prescribed || cautiously || to || prevent || iron || overload || with || repeated || transfusions. || Iron || overload || damages || the || heart, || liver, || and || endocrine || organs. || monitor || the || client's || serum || ferritin, || serum || iron, || and || total || iron-binding || capacity || during || transfusion || therapy. || the || other || laboratory || values || should || not || result || in || discontinuation || of || the || transfusion || by || the || nurse. A || client || is || newly || diagnosed || with || sickle || cell || anemia. || Which || information || does || the || nurse || include || in || the || clients || discharge || instructions?
D. || Number || of || RBCs || - || ✔✔B. || Tissue || hypoxia Hemoglobin || does || not || directly || control || RBC || production. || If || there || is || insufficient || hemoglobin || to || adequately || oxygenate || the || tissue, || then || erythropoietin || may || be || released. || When || tissue || hypoxia || occurs, || the || kidneys || release || erythropoietin || into || the || bloodstream. || This || stimulates || the || marrow || to || produce || new || RBCs. || Reticulocytes || are || immature || RBCs. || The || metic || count || can || be || used || to || monitor || hematopoiesis. || The || number || of || RBCs || does || not || directly || control || production. || In || congenital || cardiac || disorders || with || mixed || blood || flow || or || decreased || pulmonary || blood || flow, || RBC || production || continues || secondary || to || tissue || hypoxia. What || condition || occurs || when || the || normal || adult || hemoglobin || is || partly || or || completely || replaced || by || abnormal || hemoglobin? A. || Aplastic || anemia B. || Sickle || cell || anemia C. || Thalassemia || major D. || Iron || deficiency || anemia || - || ✔✔B. || Sickle || cell || anemia Sickle || cell || anemia || is || one || of || the || group || of || diseases || collectively || called || hemoglobinopathies, || in || which || normal || adult || hemoglobin || is || replaced || by || abnormal || hemoglobin. || Aplastic || anemia || is || a || lack || of || cellular || elements || being || produced. || Thalassemia || major || refers || to || a || variety || of || inherited || disorders || characterized || by || deficiencies || in || production || of || certain || globulin || chains. || Iron-deficiency || anemia || affects || red || blood || cell || size || and || depth || of || color || but || does || not || involve || abnormal || hemoglobin. The || parents || of || a || child || with || sickle || cell || anemia || are || concerned || about || subsequent || children || having || the || disease. || What || statement || most || accurately || reflects || inheritance || of || SCA? A. || SCA || is || not || inherited B.All || siblings || will || have || SCA C. || Each || sibling || has || a || 25% || chance || of || having || SCA D. || There || is || a || 50% || chance || of || siblings || having || SCA || - || ✔✔C. || Each || sibling || has || a || 25% || chance || of || having || SCA
SCA || is || inherited || as || an || autosomal || recessive || disorder. || In || this || inheritance || pattern, || each || child || born || to || these || parents || has || a || 25% || chance || of || having || the || disorder, || a || 25% || chance || of || have || neither || SCA || nor || the || trait, || and || a || 50% || chance || of || being || heterozygous || for || SCA. || SCA || is || an || inherited || hemoglobinopathy The || clinical || manifestations || of || sickle || cell || anemia || (SCA) || are || primarily || the || result || of || which || physiologic || alteration? A. || Decreased || blood || viscosity B. || Deficiency || in || coagulation C. || Increased || RBC || destruction D. || Greater || affinity || for || oxygen || - || ✔✔C. || Increased || RBC || destruction The || clinical || features || of || SCA || are || primarily || the || result || of || increased || RBC || destruction || and || obstruction || caused || by || the || sickle-shaped || RBCs. || When || the || sickle || cells || change || shape, || they || increase || the || viscosity || in || the || area || where || they || are || involved || in || the || microcirculation. || SCA || dose || not || have || a || coagulation || deficit. || Sickled || red || cells || have || decreased || oxygen-carrying || capacity || and || transform || into || the || sickle || shape || in || conditions || of || low || oxygen || tension A || school-age || child || is || admitted || in || vasooclusive || sickle || cell || crisis || (pain || episode). || The || child's || care || should || include || which || therapeutic || interventions? A. || Hydration || and || pain || management B. || Oxygenation || and || factor || VIII || replacement C. || Electrolyte || replacement || and || administration || of || heparin D. || Correction || of || alkalosis || and || reduction || of || energy || expenditure || - || ✔✔A. || Hydration || and || pain || management The || management || of || crises || include || adequate || hydration, || pain || management, || minimization || of || energy || expenditures, || electrolyte || replacement, || and || blood || component || therapy || if || indicated. || Factor || VIII || is || not || indicated || in || the || treatment || of || vaso-occlusive || sickle || cell || crisis.
Children || with || SCA || have || impaired || kidney || function || and || cannot || concentrate || urine. || Parents || are || taught || signs || of || dehydration || and || ways || to || minimize || loss || of || fluid || of || fluid || to || the || environment. || Encouraging || drinking || is || not || specific || enough || for || parents. || The || nurse || should || give || the || parents || and || child || a || target || fluid || amount || for || each || 24-hour || period. || Accurate || monitoring || of || output || may || not || reflect || the || child's || fluid || needs. || Without || the || ability || to || concentrate || urine, || the || child || needs || additional || intake || to || compensate. || Dilute || urine || and || specific || gravity || are || not || valid || signs || of || hydration || status || in || children || with || SCA. A || 5-year-old || child || is || admitted || to || the || hospital || in || a || sickle || cell || crisis. || The || child || has || been || alert || and || oriented || but || in || severe || pain. || The || nurse || notes || that || the || child || is || complaining || of || headache || and || is || having || unilateral || hemiplegia. || What || action || should || the || nurse || implement? A. || Notify || the || health || care || provider B. || Place || the || child || on || bed || rest C. || Administer || a || dose || of || hydrocodone || (Vicodin) D. || Start || Ó || per || the || hospitals || protocol. || - || ✔✔A. || Notify || the || health || care || provider Any || number || of || neurologic || symptoms || can || indicate || a || minor || cerebral || insult, || such || as || headache, || aphasia, || weakness, || convulsions, || visual || disturbances, || or || unilateral || hemiplegia. || Loss || of || vision || is || usually || the || result || of || progressive || retinopathy || and || retinal || detachment. || The || nurse || should || notify || the || health || care || provider. What || pain || medication || is || contraindicated || in || children || with || sickle || cell || disease || (SCD)? A. || Meperidine B. || Hydrocodone C. || Morphine || sulfate D. || Ketorolac || - || ✔✔A. || Meperidine Meperidine || is || not || recommended. || Normeperidine, || a || metabolite || of || meperidine, || is || a || central || nervous || system || stimulant || that || produces || anxiety, || tremors, || myoclonus, || and || generalized || seizures || when || is || accumulates || with || repetitive || dosing. || Patients || with || SCD || are || particularly || at || risk || for || normeperidine-induced || seizures.
A || child || with || sickle || cell || disease || is || vase-occlusive || crisis. || What || nonpharmacologic || pain || intervention || should || the || nurse || plan? A. || Exercise || as || a || distraction B. || Heat || to || the || affected || area C. || Elevation || of || the || extremity D. || Cold || compresses || to || the || affected || area || - || ✔✔B. || Heat || to || the || affected || area Frequently, || heat || to || the || affected || area || is || soothing. || Cold || compresses || are || not || applied || to || the || area || because || doing || so || enhances || vasoconstriction || and || occlusion. || bed || rest || is || usually || well || tolerated || during || a || crisis, || altho || the || actual || ret || obtained || depends || a || great || deal || on || pain || alleviation || and || the || use || of || organized || schedules || of || nursing || care. || Although || the || objective || of || bed || rest || s || to || minimize || oxygen || consumption, || some || activity, || particularly || passive || range || of || motion || exercises, || is || beneficial || to || promote || circulation. || Usually || the || best || course || is || to || let || children || determine || their || activity || tolerance. || elevating || the || extremity || will || not || help || in || sickle || cell || disease. The || nurse || is || caring || for || a || patient || with || increased || intracranial || pressure. || Which || action || is || considered || unsafe? A. || Aligning || the || neck || with || the || body B. || Clustering || many || nursing || activities C. || Elevating || the || head || of || the || bed || 30 || degrees D. || Providing || stool || softeners || or || laxatives || as || ordered || - || ✔✔B. || Clustering || many || nursing || activities It || is || important || to || minimize || stress || and || activities || that || could || increase || ICP. || Combining || many || nursing || activities || could || increase || oxygen || demand || and || ICP. || This || would || not || be || safe. || Interventions || which || can || promote || venous || outflow || can || help || decrease || ICP. || The || stress || of || constipation || or || bowel || movements || can || increase || ICP; || stool || softener || or || laxatives || can || minimize || this.
A. || Blood || pressure B. || Cranial || nerve || function C. || Head || circumference D. || Verbal || responsiveness || - || ✔✔D. || Verbal || responsiveness Components || of || GCS || include || eye || opening, || motor || responsiveness || , || and || verbal || responsiveness. || The || nurse || would || want || to || assess || the || blood || pressure, || but || this || is || not || a || component || of || comma || scale. || Assessment || of || cranial || nerve || function || is || appropriate || as || alterations || such || as || cranial || nerve || VI || palsies || may || occur, || but || this || is || not || part || of || the || coma || scale. || Increases || in || head || circumference || are || associated || with || alterations || in || ICP || in || infants, || but || this || is || not || part || of || the || coma || scale. Primary || prevention || strategies || to || reduce || the || occurrence || of || head || injuries || would || include A. || Blood || pressure || control B. || Smoking || cessation C. || Maintaining || a || healthy || weight D. || Violence || prevention || - || ✔✔D. || Violence || prevention Injury || prevention || measures || such || as || wearing || a || seat || belt, || helmet || use, || firearm || safety, || and || violence || prevention || programs || reduce || the || risk || of || traumatic || brain || injuries. || Blood || pressure || control || and || exercising || can || decrease || the || risk || of || vascular || disease, || impacting || the || cerebral || arteries, || rather || than || head || injuries. || Smoking || cessation || is || one || primary || prevention || strategy || which || can || decrease || the || risk || of || vascular || disease. || Maintaining || a || healthy || weight || can || decrease || the || risk || of || vascular || disease. A || nurse || plans || care || for || a || client || who || has || a || hypoactive || response || to || a || test || of || deep || tendon || reflexes. || Which || intervention || should || the || nurse || include || in || this || client's || plan || of || care? A. || Check || bath || water || temperature || wit || a || thermometer B. || Provide || the || client || with || assistance || when || ambulating C. || Place || elastic || support || hose || on || the || client's || legs
D. || Assess || the || client's || feet || for || wounds || each || shift. || - || ✔✔B. || Provide || the || client || with || assistance || when || ambulating Hypoative || deep || tendon || reflexes || and || loss || of || vibration || sense || can || impair || balance || and || coordination, || predisposing || the || client || to || falls. || The || nurse || should || plan || to || provide || the || client || with || ambulation || assistance || to || prevent || injury. || The || other || interventions || do || not || address || the || clients || problem. A || nurse || assesses || a || client's || recent || memory. || Which || client || statement || confirms || that || the || clients || remote || memory || is || intact? A. || A || young || girl || wrapped || in || a || shroud || fell || asleep || on || a || bed || of || clouds B. || I || was || born || on || April || 3rd, || 1967, || in || Jonhstown || Community || Hospital C. || Apple, || chair, || and || pencil || are || the || words || you || just || stated D. || I || ate || oatmeal || with || wheat || toast || and || orange || juice || for || breakfast || - || ✔✔D. || I || ate || oatmeal || with || wheat || toast || and || orange || juice || for || breakfast Asking || clients || about || recent || events || that || can || be || verified, || such || as || what || the || client || ate || for || breakfast, || assesses || the || client's || recent || memory. || The || client's || ability || to || make || up || a || rhyme || tests || not || memory, || bu || rather || a || higher || level || of || cognition. || Asking || clients || about || certain || facts || from || the || past || can || be || verified || assesses || remote || or || long-term || memory. || Asking || the || client || to || repeat || words || assesses || the || client's || immediate || memory. A || nurse || assesses || a || client || who || demonstrates || a || positive || Romberg's || sign || with || eyes || closed || but || not || with || eyes || open. || Which || condition || does || the || nurse || associate || with || this || finding? A. || Difficulty || with || proprioception B. || Peripheral || motor || disorder C. || Impaired || cerebella || function D. || Positive || pronator || drift || - || ✔✔A. || Difficulty || with || proprioception
on || bedrest; || therefore, || orthostatic || blood || pressure || readings || cannot || be || performed. || The || funduscopic || examination || would || be || affected || by || cerebral || angiography. || The || client || is || given || analgesics || but || not || conscious || sedation; || therefore, || the || clients || gag || reflex || would || not || be || compormised. A || nurse || obtained || a || focused || health || history || for || a || client || who || is || scheduled || for || magnetic || resonance || angiography. || Which || priority || question || should || the || nurse || ask || before || the || test? A. || Have || you || had || a || recent || blood || transfusion? B. || Do || you || have || allergies || to || iodine || or || shellfish? C. || Are || you || taking || any || cardiac || medications? D. || Do || you || currently || use || oral || contraceptives? || - || ✔✔B. || Do || you || have || allergies || to || iodine || or || shellfish? Allergies || to || iodine || and/or || shellfish || need || to || be || explored || because || the || client || may || have || a || similar || reaction || t || the || dye || used || in || the || procedure. || In || some || cases, || the || client || ay || need || to || be || medicated || with || antihistamines || or || steroid || before || the || test || is || given. || A || recent || blood || transfusion || or || current || use || of || cardiac || medications || or || oral || contraceptives || would || not || affect || the || angiography A || nurse || obtained || a || focused || health || history || for || a || client || who || is || scheduled || for || an || MRI. || Which || condition || should || alert || the || nurse || to || contact || the || provider || and || cancel || the || procedure? || A. || Creatine || phosphokinase || of || 100 B. || Atriventricular || graft C. || BUN || of || 50 D. || Internal || insulin || pump || - || ✔✔D. || Internal || insulin || pump Metal || devices || such || as || internal || pumps, || pacemakers, || and || prostheses || interfere || with || accuracy || of || the || image || and || can || become || displaced || by || the || magnetic || force || generated || by || an || MRI || procedure. || An || artioventricular || graft || does || not || contain || any || metal. || CPK || and || BUN || levels || have || no || impact || on || an || MRI || procedure
A || nurse || teaches || a || client || who || is || scheduled || for || a || positron || emission || tomography || scan || of || their || brain. || Which || statement || should || the || nurse || include || in || this || clients || teaching? A. || Avoid || caffeine-containing || substances || for || 12 || hours || before || the || test B. || Drink || at || least || 3 || liters || of || fluid || during || the || 24 || hours || after || the || test C. || Do || not || take || your || cardiac || medication || the || morning || of || the || test D. || Remove || your || dentures || and || any || metal || before || the || test || begins || - || ✔✔A. || Avoid || caffeine- containing || substances || for || 12 || hours || before || the || test Caffeine-containing || liquids || and || foods || are || central || nervous || system || stimulants || ad || may || alter || the || test || results. || No || contrast || is || used; || therefore, || the || client || does || not || need || to || increase || fluid || intake. || Th || client || should || take || cardiac || medications || as || prescribed. || Metal || does || not || have || to || be || removed; || this || is || done || for || MRI. A || nurse || cares || for || a || client || who || is || experiencing || deteriorating || neurologic || functions. || The || client || states, || I || am || worried || I || will || not || be || able || to || care || for || my || young || children. || How || should || the || nurse || respond? A. || Caring || for || your || young || children || is || a || priority. || You || may || not || want || to || ask || for || help, || but || you || have || too. B. || Our || community || has || resources || that || may || help || you || with || some || household || tasks || so || you || have || energy || to || care || for || your || children. C. || You || seem || distressed. || Would || you || like || to || talk || to || a || psychologist || about || adjusting || to || your || changing || status? D. || Give || me || more || information || about || what || worries || you, || so || we || can || see || if || we || can || do || something || to || make || adjustments. || - || ✔✔D. || Give || me || some || more || information || about || what || worries || you, || so || we || can || see || if || we || can || do || something || to || make || adjustments Investigate || specific || concerns || about || situational || or || role || changes || before || providing || additional || information. || The || nurse || should || not || tell || the || client || what || is || or || is || not || a || priority || for || him || or || her. || Although || community || resources || may || be || available, || they || may || not || be || appropriate || for ||
A || nurse || assesses || a || client || with || a || brain || tumor. || The || client || opens || his || eyes || when || the || nurse || calls || his || name, || mumbles || in || response || to || questions, || and || follows || simple || commands. || How || should || the || nurse || document || the || client's || assessment || using || the || GCS? A. || 8 B. || 10 C. || 12 D. || 14 || - || ✔✔C. || 12 The || client || opens || his || eyes || to || speech || (Eye || opening: || to || sound || = || 3), || mumbles || in || response || to || questions || (Verbal || response: || Inappropriate || words || = || 3), || and || follows || simple || commands || (Motor || response: || Obey || commands || = || 6). || Therefore, || the || clients || GCS || is: || 3+3+6 || = || 12 After || administering || a || medication || that || stimulates || the || sympathetic || division || of || the || autonomic || nervous || system, || the || nurse || assesses || the || client. || For || which || clinical || manifestations || should || the || nurse || assess? || (Select || all || that || apply) A. || Decreased || respiratory || rate B. || Increased || heart || rate C. || Decreased || level || of || consciousness D. || Increased || force || of || contraction E. || Decreased || blood || pressure || - || ✔✔B,D Stimulation || of || the || sympathetic || nervous || system || initiates || the || fight-or-flight || response, || increasing || heart || rate || and || force || of || contraction. || A || medication || that || stimulates || the || sympathetic || nervous || system || would || also || increase || the || client's || respiratory || rate, || blood || pressure, || and || level || of || consciousness A || nurse || assesses || a || client || with || a || brain || tumor. || Which || newly || identified || assessment || findings || alert || the || nurse || to || urgently || communicate || with || the || health || care || provider? || (Select || all || that || apply)
A. || GCS || of || 8 B. || Decerebrate || posturing C. || Reactive || pupils D. || Uninhibited || speech E. || Diminished || cognition || - || ✔✔A,B,E The || nurse || should || urgently || communicate || changes || in || a || clients || neurologic || status, || including || a || decrease || in || the || GCS, || abnormal || flexion || or || extension, || changes || in || cognition || or || speech, || and || pinpointed, || dilated, || and || nonreactive || pupils A || nurse || assesses || an || older || client. || Which || assessment || findings || should || the || nurse || identify || as || normal || changes || in || the || nervous || system || related || to || aging? || (Select || all || that || apply) A. || Long-term || memory || loss B. || Slower || processing || time C. || Increased || sensory || perception D. || Decreased || risk || for || infection E. || Change || in || sleep || patterns || - || ✔✔B,E Normal || changes || in || the || nervous || system || related || to || aging || include || recent || memory || loss, || slower || processing || time, || decreased || sensory || perception, || an || increased || risk || for || infection, || changes || in || sleep || patterns, || changes || in || perception || of || pain, || and || altered || balance || and/or || decreased || coordination. A || clients || mean || arterial || pressure || is || 60 || mm || Hg || and || the || ICP || is || 20 || mm || Hg. || Based || on || the || client's || cerebral || perfusion || pressure, || what || should || the || nurse || anticipate || for || this || client? A. || Impending || brain || herniation B. || Poor || prognosis || and || cognitive || function C. || Probable || complete || recovery D. || Unable || to || tell || from || this || information || - || ✔✔B. || Poor || prognosis || and || cognitive || function
