1
NSG 4100 Exam 4 Q&A Questions with Solutions
Newest Complete Questions And Correct Detailed
Answers| Already Graded A+
Part 1: Neurological Emergencies (Traumatic Brain Injury, Increased ICP, Meningitis, Encephalitis,
Myasthenia Gravis)
Q1. A nurse is assessing a patient with a traumatic brain injury. Which assessment finding is most
indicative of worsening neurological status and increased ICP?
A. Pupil size changing from 5mm to 9mm
B. Heart rate increase from 72 to 88 bpm
C. Blood pressure decrease from 130/80 to 110/70
D. Respiratory rate increase from 16 to 20 breaths/min
Answer: A
Rationale: Pupillary dilation from compression of the oculomotor nerve (CN III) is a late sign of
herniation from significantly increased ICP. Vital sign changes may occur but are less specific. Cushing's
triad (hypertension, bradycardia, irregular respirations) is a late finding. High blood pressure is a priority
over a high heart rate in neurological emergencies.
Q2. Which patient position is best for a patient who is at risk for increased intracranial pressure?
A. Supine position with head flat
B. Trendelenburg position
C. Semi-Fowler's position with head of bed elevated 30-45 degrees
D. Prone position
Answer: C
Rationale: Elevating the head of bed to 30-45 degrees (semi-Fowler's) promotes venous drainage from
the brain and helps reduce ICP. The Trendelenburg position would increase ICP. Keep head in neutral
position—no head rotation—to promote venous drainage.
Q3. The nurse caring for a client with a head injury would recognize which assessment findings as early
signs of increased ICP? Select all that apply:
A. Kussmaul breathing
B. Projectile vomiting
C. Weakness in one extremity
D. Headache not aggravated by movement or straining
,2
E. Decreased urine output
F. Papilledema
Answer: A, C, D
Rationale: Early signs of increased ICP include changes in LOC, headache (often worse in the morning),
weakness in one extremity or on one side, and altered respiratory patterns such as Kussmaul breathing.
Vomiting without nausea, sudden restlessness, and Cushing's triad are late signs.
Q4. A critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who,
on morning rounds, is responsive to painful stimulus and assumes decorticate posturing. Two hours
later, which data would warrant immediate intervention by the nurse?
A. The client has purposeful movement when the nurse rubs the sternum
B. The client extends the upper and lower extremities in response to painful stimuli
C. The client is aimlessly thrashing in the bed when a noxious stimulus is applied
D. The client opens eyes to verbal command
Answer: B
Rationale: Progression from decorticate posturing (flexion) to decerebrate posturing (extension of upper
and lower extremities) indicates worsening neurological function and brainstem involvement, requiring
immediate intervention. Decorticate = flexion (stiff legs, fist clenched, arms bent to chest); decerebrate
= extension (arms and legs straight out, toes pointed down, head and neck arched).
Q5. The nurse is caring for clients in the ED. Which client should the nurse assess first?
A. The client with an epidural hematoma
B. The client who had a seizure who is in the postictal state
C. The client diagnosed with R/O encephalitis who has a headache
D. The client with multiple sclerosis who has scanning speech
Answer: A
Rationale: An epidural hematoma is a neurosurgical emergency caused by arterial bleeding, which can
rapidly lead to increased ICP and herniation. This client requires immediate assessment and
intervention. CSF from ear, bruising over the mastoid bone (Battle sign), and temperature over 100.4°F
are immediate intervention triggers.
Q6. A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this patient's care, the nurse would expect to administer what priority
medication?
A. Hydrochlorothiazide (HydroDIURIL)
B. Furosemide (Lasix)
C. Mannitol (Osmitrol)
D. Spironolactone (Aldactone)
,3
Answer: C
Rationale: Mannitol is an osmotic diuretic that draws fluid from the brain tissue into the vascular space,
effectively reducing cerebral edema and lowering ICP. Hypertonic saline solutions may also be used.
Q7. The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan
of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
A. Change the patient's position as indicated
B. Monitor serum electrolytes
C. Maintain NPO status
D. Monitor arterial blood gas (ABG) values
Answer: B
Rationale: Osmotic diuretics like mannitol can cause significant electrolyte imbalances, particularly
hyponatremia and hypokalemia. Serum electrolytes must be closely monitored. Post-craniotomy, if
drain output is 50-100 mL per shift, that is too much—call the provider.
Q8. A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of
the adverse effects of this medication, the nurse should prioritize which assessment?
A. Cardiovascular assessment
B. Oral hygiene and gum assessment
C. Respiratory assessment
D. Gastrointestinal assessment
Answer: B
Rationale: Long-term phenytoin use is associated with gingival hyperplasia (overgrowth of gum tissue).
The nurse should assess the oral cavity and reinforce the importance of good oral hygiene and regular
dental care.
Q9. A client with a traumatic brain injury has been producing a large amount of urine for the past 3
hours and is becoming tachycardic and hypotensive. The nurse knows that this client needs to be closely
monitored for developing which condition?
A. Cushing syndrome, which is treated with intermittent doses of corticoids
B. Diabetes insipidus (DI), which is treated with antidiuretic hormone (Vasopressin)
C. SIADH, which is treated with ADH
D. Diabetes mellitus, which is treated with basal analog insulin
Answer: B
Rationale: Damage to the hypothalamus or pituitary gland can cause a deficiency of ADH, resulting in
diabetes insipidus. This is characterized by massive diuresis of dilute urine (urine specific gravity ~1.010),
leading to dehydration, tachycardia, and hypotension. A patient voiding a lot in a short time is a
concern.
, 4
Q10. A client with a pituitary tumor developed SIADH. Which intervention should the nurse implement?
A. Assess for dehydration and monitor blood glucose level
B. Assess for nausea and vomiting and weigh daily
C. Monitor potassium level and encourage fluid intake
D. Administer vasopressin IV and conduct fluid deprivation test
Answer: B
Rationale: SIADH is characterized by excessive ADH secretion, leading to water retention and dilutional
hyponatremia. The nurse should monitor for signs of fluid overload (daily weight is the best indicator),
nausea/vomiting, and neurological changes due to hyponatremia.
Q11. A 69-year-old patient is brought to the ED and is diagnosed with bacterial meningitis. The nurse
knows that risk factors for an unfavorable outcome include what? Select all that apply:
A. BP greater than 140/90 mm Hg
B. HR greater than 120 bpm
C. Older age
D. Low Glasgow Coma Scale score
E. Lack of previous immunizations
Answer: B, C, D
Rationale: Risk factors for poor outcomes in bacterial meningitis include older age, tachycardia (>120
bpm), and a low Glasgow Coma Scale score on admission. Prevention includes meningococcal
immunization at 11-12 years old with a booster at 16.
Q12. What nursing action best addresses a patient's complaint of headache in a patient with suspected
herpes simplex virus encephalitis?
A. Initiating a patient-controlled analgesia (PCA) of morphine sulfate
B. Administering hydromorphone (Dilaudid) IV as needed
C. Dimming the lights and reducing stimulation
D. Distracting the patient with activity
Answer: C
Rationale: Encephalitis causes inflammation of the brain tissue, leading to photophobia and severe
headache. Non-pharmacologic comfort measures include dimming lights, reducing noise, clustering
care, limiting visitors, and placing the patient away from the nurses' station.
Q13. A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical
feature of St. Louis encephalitis will make what nursing action a priority?
A. Serial assessments of hemoglobin levels
B. Blood glucose monitoring
NSG 4100 Exam 4 Q&A Questions with Solutions
Newest Complete Questions And Correct Detailed
Answers| Already Graded A+
Part 1: Neurological Emergencies (Traumatic Brain Injury, Increased ICP, Meningitis, Encephalitis,
Myasthenia Gravis)
Q1. A nurse is assessing a patient with a traumatic brain injury. Which assessment finding is most
indicative of worsening neurological status and increased ICP?
A. Pupil size changing from 5mm to 9mm
B. Heart rate increase from 72 to 88 bpm
C. Blood pressure decrease from 130/80 to 110/70
D. Respiratory rate increase from 16 to 20 breaths/min
Answer: A
Rationale: Pupillary dilation from compression of the oculomotor nerve (CN III) is a late sign of
herniation from significantly increased ICP. Vital sign changes may occur but are less specific. Cushing's
triad (hypertension, bradycardia, irregular respirations) is a late finding. High blood pressure is a priority
over a high heart rate in neurological emergencies.
Q2. Which patient position is best for a patient who is at risk for increased intracranial pressure?
A. Supine position with head flat
B. Trendelenburg position
C. Semi-Fowler's position with head of bed elevated 30-45 degrees
D. Prone position
Answer: C
Rationale: Elevating the head of bed to 30-45 degrees (semi-Fowler's) promotes venous drainage from
the brain and helps reduce ICP. The Trendelenburg position would increase ICP. Keep head in neutral
position—no head rotation—to promote venous drainage.
Q3. The nurse caring for a client with a head injury would recognize which assessment findings as early
signs of increased ICP? Select all that apply:
A. Kussmaul breathing
B. Projectile vomiting
C. Weakness in one extremity
D. Headache not aggravated by movement or straining
,2
E. Decreased urine output
F. Papilledema
Answer: A, C, D
Rationale: Early signs of increased ICP include changes in LOC, headache (often worse in the morning),
weakness in one extremity or on one side, and altered respiratory patterns such as Kussmaul breathing.
Vomiting without nausea, sudden restlessness, and Cushing's triad are late signs.
Q4. A critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who,
on morning rounds, is responsive to painful stimulus and assumes decorticate posturing. Two hours
later, which data would warrant immediate intervention by the nurse?
A. The client has purposeful movement when the nurse rubs the sternum
B. The client extends the upper and lower extremities in response to painful stimuli
C. The client is aimlessly thrashing in the bed when a noxious stimulus is applied
D. The client opens eyes to verbal command
Answer: B
Rationale: Progression from decorticate posturing (flexion) to decerebrate posturing (extension of upper
and lower extremities) indicates worsening neurological function and brainstem involvement, requiring
immediate intervention. Decorticate = flexion (stiff legs, fist clenched, arms bent to chest); decerebrate
= extension (arms and legs straight out, toes pointed down, head and neck arched).
Q5. The nurse is caring for clients in the ED. Which client should the nurse assess first?
A. The client with an epidural hematoma
B. The client who had a seizure who is in the postictal state
C. The client diagnosed with R/O encephalitis who has a headache
D. The client with multiple sclerosis who has scanning speech
Answer: A
Rationale: An epidural hematoma is a neurosurgical emergency caused by arterial bleeding, which can
rapidly lead to increased ICP and herniation. This client requires immediate assessment and
intervention. CSF from ear, bruising over the mastoid bone (Battle sign), and temperature over 100.4°F
are immediate intervention triggers.
Q6. A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this patient's care, the nurse would expect to administer what priority
medication?
A. Hydrochlorothiazide (HydroDIURIL)
B. Furosemide (Lasix)
C. Mannitol (Osmitrol)
D. Spironolactone (Aldactone)
,3
Answer: C
Rationale: Mannitol is an osmotic diuretic that draws fluid from the brain tissue into the vascular space,
effectively reducing cerebral edema and lowering ICP. Hypertonic saline solutions may also be used.
Q7. The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan
of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
A. Change the patient's position as indicated
B. Monitor serum electrolytes
C. Maintain NPO status
D. Monitor arterial blood gas (ABG) values
Answer: B
Rationale: Osmotic diuretics like mannitol can cause significant electrolyte imbalances, particularly
hyponatremia and hypokalemia. Serum electrolytes must be closely monitored. Post-craniotomy, if
drain output is 50-100 mL per shift, that is too much—call the provider.
Q8. A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of
the adverse effects of this medication, the nurse should prioritize which assessment?
A. Cardiovascular assessment
B. Oral hygiene and gum assessment
C. Respiratory assessment
D. Gastrointestinal assessment
Answer: B
Rationale: Long-term phenytoin use is associated with gingival hyperplasia (overgrowth of gum tissue).
The nurse should assess the oral cavity and reinforce the importance of good oral hygiene and regular
dental care.
Q9. A client with a traumatic brain injury has been producing a large amount of urine for the past 3
hours and is becoming tachycardic and hypotensive. The nurse knows that this client needs to be closely
monitored for developing which condition?
A. Cushing syndrome, which is treated with intermittent doses of corticoids
B. Diabetes insipidus (DI), which is treated with antidiuretic hormone (Vasopressin)
C. SIADH, which is treated with ADH
D. Diabetes mellitus, which is treated with basal analog insulin
Answer: B
Rationale: Damage to the hypothalamus or pituitary gland can cause a deficiency of ADH, resulting in
diabetes insipidus. This is characterized by massive diuresis of dilute urine (urine specific gravity ~1.010),
leading to dehydration, tachycardia, and hypotension. A patient voiding a lot in a short time is a
concern.
, 4
Q10. A client with a pituitary tumor developed SIADH. Which intervention should the nurse implement?
A. Assess for dehydration and monitor blood glucose level
B. Assess for nausea and vomiting and weigh daily
C. Monitor potassium level and encourage fluid intake
D. Administer vasopressin IV and conduct fluid deprivation test
Answer: B
Rationale: SIADH is characterized by excessive ADH secretion, leading to water retention and dilutional
hyponatremia. The nurse should monitor for signs of fluid overload (daily weight is the best indicator),
nausea/vomiting, and neurological changes due to hyponatremia.
Q11. A 69-year-old patient is brought to the ED and is diagnosed with bacterial meningitis. The nurse
knows that risk factors for an unfavorable outcome include what? Select all that apply:
A. BP greater than 140/90 mm Hg
B. HR greater than 120 bpm
C. Older age
D. Low Glasgow Coma Scale score
E. Lack of previous immunizations
Answer: B, C, D
Rationale: Risk factors for poor outcomes in bacterial meningitis include older age, tachycardia (>120
bpm), and a low Glasgow Coma Scale score on admission. Prevention includes meningococcal
immunization at 11-12 years old with a booster at 16.
Q12. What nursing action best addresses a patient's complaint of headache in a patient with suspected
herpes simplex virus encephalitis?
A. Initiating a patient-controlled analgesia (PCA) of morphine sulfate
B. Administering hydromorphone (Dilaudid) IV as needed
C. Dimming the lights and reducing stimulation
D. Distracting the patient with activity
Answer: C
Rationale: Encephalitis causes inflammation of the brain tissue, leading to photophobia and severe
headache. Non-pharmacologic comfort measures include dimming lights, reducing noise, clustering
care, limiting visitors, and placing the patient away from the nurses' station.
Q13. A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical
feature of St. Louis encephalitis will make what nursing action a priority?
A. Serial assessments of hemoglobin levels
B. Blood glucose monitoring
