NSG 4100 (AH III) Exam 4
1. The nurse is caring for a client with a Head Injury who is experiencing Increased Intracranial
Pressure (ICP). Which of the following is the earliest sign of increased ICP?
A. Widening pulse pressure and bradycardia B. Change in Level of Consciousness (LOC)
C. Fixed and dilated pupils D. Decerebrate posturing
Annotation: LOC = FIRST SIGN. They might be confused, restless, or just “not
themselves.” Cushing’s Triad (HTN, Bradycardia, Widening Pulse Pressure) is a LATE
sign.
2. A client with Increased ICP is prescribed Mannitol (Osmitrol). What is the primary rationale
for this medication?
A. To lower blood pressure B. To reduce cerebral edema by pulling fluid into the
vascular space C. To prevent seizures D. To increase cardiac output
Annotation: MANNITOL = OSMOTIC DIURETIC. It’s like a “sponge” for the brain. It
pulls water out of the brain cells and into the blood to be peed out. Watch for
crystals in the tubing!
3. The nurse is assessing a client with a C5 Spinal Cord Injury (SCI). Which of the following is
the priority assessment?
A. Respiratory status and airway patency B. Muscle strength in the lower extremities C.
Bowel and bladder function D. Skin integrity over bony prominences
Annotation: C3, C4, C5 KEEP THE DIAPHRAGM ALIVE! Any injury at or above C5 can
paralyze the diaphragm. Always have intubation equipment ready.
4. A client with a T6 SCI reports a severe, throbbing headache and has a blood pressure of
210/110 mmHg. What is the nurse’s priority action?
A. Administer a PRN dose of antihypertensive medication B. Sit the client upright and
check for a full bladder or fecal impaction C. Notify the provider and prepare for a CT
scan D. Administer a dose of pain medication
Annotation: AUTONOMIC DYSREFLEXIA = EMERGENCY! It’s caused by a noxious
stimulus (usually a full bladder). SIT THEM UP FIRST to lower BP, then find the
cause.
, 5. The nurse is caring for a client in Septic Shock. Which of the following findings is
characteristic of the compensatory stage?
A. Hypotension and bradycardia B. Tachycardia, tachypnea, and normal blood pressure
C. Anuria and metabolic acidosis D. Lethargy and cold, clammy skin
Annotation: COMPENSATORY = FIGHTING BACK. The body is trying to maintain BP
by increasing HR and RR. If you don’t catch it here, it moves to the Progressive stage
(BP drops).
6. A client is admitted with Hypovolemic Shock due to severe hemorrhage. Which of the
following is the priority intervention?
A. Rapid IV fluid resuscitation with crystalloids and blood products B. Administration
of vasopressors (e.g., Norepinephrine) C. Monitoring for signs of infection D. Teaching the
client about the importance of hydration
Annotation: VOLUME FIRST! You can’t “squeeze” an empty tank. Give fluids (NS/LR)
and blood before you give vasopressors.
7. The nurse is assessing a client with Myasthenia Gravis (MG). Which of the following
findings is most characteristic?
A. Muscle rigidity and tremors B. Ptosis (drooping eyelid) and muscle weakness that
worsens with activity C. Loss of sensation in the lower extremities D. Sudden onset of
severe headache
Annotation: MG = “GRAVE MUSCLE WEAKNESS.” It’s an autoimmune attack on
acetylcholine receptors. Weakness gets WORSE as the day goes on. Give meds
(Pyridostigmine) ON TIME.
8. A client with MG is experiencing a Myasthenic Crisis. Which of the following is the priority
intervention?
A. Maintaining a patent airway and mechanical ventilation B. Administering a dose of
Edrophonium (Tensilon) C. Encouraging the client to perform deep breathing exercises D.
Administering IV corticosteroids
Annotation: CRISIS = RESPIRATORY FAILURE. The muscles for breathing are too
weak. Tensilon test is used to diagnose, but AIRWAY is the priority.
1. The nurse is caring for a client with a Head Injury who is experiencing Increased Intracranial
Pressure (ICP). Which of the following is the earliest sign of increased ICP?
A. Widening pulse pressure and bradycardia B. Change in Level of Consciousness (LOC)
C. Fixed and dilated pupils D. Decerebrate posturing
Annotation: LOC = FIRST SIGN. They might be confused, restless, or just “not
themselves.” Cushing’s Triad (HTN, Bradycardia, Widening Pulse Pressure) is a LATE
sign.
2. A client with Increased ICP is prescribed Mannitol (Osmitrol). What is the primary rationale
for this medication?
A. To lower blood pressure B. To reduce cerebral edema by pulling fluid into the
vascular space C. To prevent seizures D. To increase cardiac output
Annotation: MANNITOL = OSMOTIC DIURETIC. It’s like a “sponge” for the brain. It
pulls water out of the brain cells and into the blood to be peed out. Watch for
crystals in the tubing!
3. The nurse is assessing a client with a C5 Spinal Cord Injury (SCI). Which of the following is
the priority assessment?
A. Respiratory status and airway patency B. Muscle strength in the lower extremities C.
Bowel and bladder function D. Skin integrity over bony prominences
Annotation: C3, C4, C5 KEEP THE DIAPHRAGM ALIVE! Any injury at or above C5 can
paralyze the diaphragm. Always have intubation equipment ready.
4. A client with a T6 SCI reports a severe, throbbing headache and has a blood pressure of
210/110 mmHg. What is the nurse’s priority action?
A. Administer a PRN dose of antihypertensive medication B. Sit the client upright and
check for a full bladder or fecal impaction C. Notify the provider and prepare for a CT
scan D. Administer a dose of pain medication
Annotation: AUTONOMIC DYSREFLEXIA = EMERGENCY! It’s caused by a noxious
stimulus (usually a full bladder). SIT THEM UP FIRST to lower BP, then find the
cause.
, 5. The nurse is caring for a client in Septic Shock. Which of the following findings is
characteristic of the compensatory stage?
A. Hypotension and bradycardia B. Tachycardia, tachypnea, and normal blood pressure
C. Anuria and metabolic acidosis D. Lethargy and cold, clammy skin
Annotation: COMPENSATORY = FIGHTING BACK. The body is trying to maintain BP
by increasing HR and RR. If you don’t catch it here, it moves to the Progressive stage
(BP drops).
6. A client is admitted with Hypovolemic Shock due to severe hemorrhage. Which of the
following is the priority intervention?
A. Rapid IV fluid resuscitation with crystalloids and blood products B. Administration
of vasopressors (e.g., Norepinephrine) C. Monitoring for signs of infection D. Teaching the
client about the importance of hydration
Annotation: VOLUME FIRST! You can’t “squeeze” an empty tank. Give fluids (NS/LR)
and blood before you give vasopressors.
7. The nurse is assessing a client with Myasthenia Gravis (MG). Which of the following
findings is most characteristic?
A. Muscle rigidity and tremors B. Ptosis (drooping eyelid) and muscle weakness that
worsens with activity C. Loss of sensation in the lower extremities D. Sudden onset of
severe headache
Annotation: MG = “GRAVE MUSCLE WEAKNESS.” It’s an autoimmune attack on
acetylcholine receptors. Weakness gets WORSE as the day goes on. Give meds
(Pyridostigmine) ON TIME.
8. A client with MG is experiencing a Myasthenic Crisis. Which of the following is the priority
intervention?
A. Maintaining a patent airway and mechanical ventilation B. Administering a dose of
Edrophonium (Tensilon) C. Encouraging the client to perform deep breathing exercises D.
Administering IV corticosteroids
Annotation: CRISIS = RESPIRATORY FAILURE. The muscles for breathing are too
weak. Tensilon test is used to diagnose, but AIRWAY is the priority.
