MSN 377 UPDATED EXAM SCRIPT QUESTIONS AND
SOLUTIONS RATED A+
✔✔A nurse in an ED is assessing a client who has myasthenia gravis. The client reports
recent increasing muscle weakness and the nurse suspects the client is having a
myasthenic crisis, which of the following actions is the nurse's priority?
A. administer artificial tears
B. assist with a tensilon test
C. administer immunosuppressants
D. assist with plasmapheresis - ✔✔B. assist with a tensilon test
The first action the nurse should take using the nursing process is to assess the client.
The Tensilon test will determine whether the client is having a myasthenic crisis or a
cholinergic crisis.
✔✔A nurse is caring for a client who has a spastic bladder following a spinal cord injury.
which of the following actions should the nurse take to help stimulate micturition?
A. encourage the client to use the valsalva maneuver
B. stroke the clients inner thigh
C. perform the crede maneuver
D. administer a diuretic - ✔✔B. stroke the clients inner thigh
The nurse should stimulate micturition by stroking the client's inner thigh. Other
techniques include pinching the skin above the groin and providing digital anal
stimulation.
✔✔A nurse is planning care for a client who has a closed head injury from a fall and is
receiving mechanical ventilation. Which of the following interventions is the nurse's
priority?
A. maintain PaCO2 of approximately 35mmHg
B. provide small doses of fentanyl via IV bolus for pain management
C. measure body temperature every 1-2 hrs
D. reposition the client every 2 hours - ✔✔A. maintain PaCO2 of approximately
35mmHg
The greatest risk to this client is injury from increased intracranial pressure. Therefore,
the nurse's priority action is to maintain the PaCO2 at 35 to 38 mm Hg to prevent
hypercarbia and subsequent vasodilation that can lead to an increase in intracranial
pressure.
✔✔Which conditions can lead to the development of a brain abscess?
A. endocarditis
B. ear infection
C. tooth abscess
D. skull fracture
, E. scalp laceration
F. sinus infection - ✔✔A. endocarditis
B. ear infection
C. tooth abscess
D. skull fracture
F. sinus infection
✔✔A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal
resection of a pituitary adenoma. What should the nurse consider as a sign of
improvement?
A. serum sodium of 120 mEq/L
B. urine specific gravity of 1.001
C. fasting blood glucose of 80 mg/dL
D. serum osmolality of 290 mOsm/kg - ✔✔D. serum osmolality of 290 mOsm/kg
Laboratory findings in diabetes insipidus include an elevation in serum osmolality and
serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275
to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific
gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.
✔✔A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why
are IV fluids being decreased and enteral feedings started?
A. free water should be avoided
B. sodium restrictions can be managed
C. dehydration can be better avoided with feedings
D. malnutrition promotes continued cerebral edema - ✔✔D. malnutrition promotes
continued cerebral edema
A patient with diffuse axonal injury is unconscious and, with increased intracranial
pressure, is in a hypermetabolic, hypercatabolic state that increases the need for
energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may
improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be
monitored to maintain balance with the enteral feedings. Excess intravenous fluid
administration will also increase cerebral edema.
✔✔The nurse is caring for a patient admitted for evaluation and surgical removal of a
brain tumor. Which complications will the nurse monitor for (select all that apply.)?
A. seizures
B. vision loss
C. cerebral edema
D. pituitary dysfunction
E. parathyroid dysfunction
F. focal neurologic defects - ✔✔A. seizures
B. vision loss
C. cerebral edema
SOLUTIONS RATED A+
✔✔A nurse in an ED is assessing a client who has myasthenia gravis. The client reports
recent increasing muscle weakness and the nurse suspects the client is having a
myasthenic crisis, which of the following actions is the nurse's priority?
A. administer artificial tears
B. assist with a tensilon test
C. administer immunosuppressants
D. assist with plasmapheresis - ✔✔B. assist with a tensilon test
The first action the nurse should take using the nursing process is to assess the client.
The Tensilon test will determine whether the client is having a myasthenic crisis or a
cholinergic crisis.
✔✔A nurse is caring for a client who has a spastic bladder following a spinal cord injury.
which of the following actions should the nurse take to help stimulate micturition?
A. encourage the client to use the valsalva maneuver
B. stroke the clients inner thigh
C. perform the crede maneuver
D. administer a diuretic - ✔✔B. stroke the clients inner thigh
The nurse should stimulate micturition by stroking the client's inner thigh. Other
techniques include pinching the skin above the groin and providing digital anal
stimulation.
✔✔A nurse is planning care for a client who has a closed head injury from a fall and is
receiving mechanical ventilation. Which of the following interventions is the nurse's
priority?
A. maintain PaCO2 of approximately 35mmHg
B. provide small doses of fentanyl via IV bolus for pain management
C. measure body temperature every 1-2 hrs
D. reposition the client every 2 hours - ✔✔A. maintain PaCO2 of approximately
35mmHg
The greatest risk to this client is injury from increased intracranial pressure. Therefore,
the nurse's priority action is to maintain the PaCO2 at 35 to 38 mm Hg to prevent
hypercarbia and subsequent vasodilation that can lead to an increase in intracranial
pressure.
✔✔Which conditions can lead to the development of a brain abscess?
A. endocarditis
B. ear infection
C. tooth abscess
D. skull fracture
, E. scalp laceration
F. sinus infection - ✔✔A. endocarditis
B. ear infection
C. tooth abscess
D. skull fracture
F. sinus infection
✔✔A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal
resection of a pituitary adenoma. What should the nurse consider as a sign of
improvement?
A. serum sodium of 120 mEq/L
B. urine specific gravity of 1.001
C. fasting blood glucose of 80 mg/dL
D. serum osmolality of 290 mOsm/kg - ✔✔D. serum osmolality of 290 mOsm/kg
Laboratory findings in diabetes insipidus include an elevation in serum osmolality and
serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275
to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific
gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.
✔✔A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why
are IV fluids being decreased and enteral feedings started?
A. free water should be avoided
B. sodium restrictions can be managed
C. dehydration can be better avoided with feedings
D. malnutrition promotes continued cerebral edema - ✔✔D. malnutrition promotes
continued cerebral edema
A patient with diffuse axonal injury is unconscious and, with increased intracranial
pressure, is in a hypermetabolic, hypercatabolic state that increases the need for
energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may
improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be
monitored to maintain balance with the enteral feedings. Excess intravenous fluid
administration will also increase cerebral edema.
✔✔The nurse is caring for a patient admitted for evaluation and surgical removal of a
brain tumor. Which complications will the nurse monitor for (select all that apply.)?
A. seizures
B. vision loss
C. cerebral edema
D. pituitary dysfunction
E. parathyroid dysfunction
F. focal neurologic defects - ✔✔A. seizures
B. vision loss
C. cerebral edema
