NSG 4100 (AHIII) EXAM 4 TESTBANK
QUESTIONS AND ANSWERS 2026
VERIFIED.
The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites, including the
neck & upper back & knees. The pt also reports non-refreshing sleep, depression, & being
anxious when dealing w multiple tasks. The nurse should teach this pt about what treatments?
Select all that apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern - ANS B, D, E
The nurse caring for a client w a head injury would recognize which assessment finding 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 of straining
e. Decreased urine output
f. Papilledema - ANS A, C, D
A nurse caring for a client diagnosed to have head injury. Which of the following situations
needs intervention by the nurse?
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,a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3 hours in the evening
d. The head of bed is elevated at 30 degree angle - ANS C
The critical care nurse is caring for a client w 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 stimuli is applied - ANS B
The nurse is caring for clients in the ED. Which client should the nurse assess first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ANS A
A female pt has experienced an episode of myasthenic crisis. The nurse would assess whether
the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ANS C
A pt is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this pt's care, the nurse would expect to administer what
priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
b. Furosemide (Lasix)
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,c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ANS C
The nurse is caring for a pt who is postoperative following a craniotomy. When writing the plan
of care, the nurse identifies a diagnosis of deficient fluid volume r/t fluid restriction & osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - ANS B
A pt who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of
the adverse of effects of this medication, the nurse should prioritize which of the following in
the pt's plan of care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - ANS C
A nurse is admitting a pt w a severe migraine headache and a hx of acute coronary syndrome.
What migraine medication would the nurse question for this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - ANS C
The nurse is caring for a pt w increased ICP. The pt has a nursing dx of ineffective cerebral tissue
perfusion. What would be an expected outcome that the nurse would document for this
diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
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, c. pays attention to grooming
d. obeys commands w appropriate motor responses - ANS D
A pt exhibiting an altered LOC due to blunt-force trauma to the head is admitted to the ED. The
physician determines the pt's injury is causing increased ICP. The nurse should gauge the pt's
LOC on the results of what diagnostic tool?
a. Monro-Kellie hypothesis
b. Glasgow Coma Scale
c. Cranial nerve function
d. mental status examination - ANS B
A pt w increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the pt is now exhibiting nuchal rigidity and photophobia. The nurse
would be correct in suspecting the presence of what complication?
a. encephalitis
b. CSF leak
c. meningitis
d. catheter occlusion - ANS C
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is
contraindicated in this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - ANS B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care plan
should specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
@COPYRIGHT ALL RIGHTS RESERVED PAGE 4 OF 47
QUESTIONS AND ANSWERS 2026
VERIFIED.
The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites, including the
neck & upper back & knees. The pt also reports non-refreshing sleep, depression, & being
anxious when dealing w multiple tasks. The nurse should teach this pt about what treatments?
Select all that apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern - ANS B, D, E
The nurse caring for a client w a head injury would recognize which assessment finding 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 of straining
e. Decreased urine output
f. Papilledema - ANS A, C, D
A nurse caring for a client diagnosed to have head injury. Which of the following situations
needs intervention by the nurse?
@COPYRIGHT ALL RIGHTS RESERVED PAGE 1 OF 47
,a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3 hours in the evening
d. The head of bed is elevated at 30 degree angle - ANS C
The critical care nurse is caring for a client w 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 stimuli is applied - ANS B
The nurse is caring for clients in the ED. Which client should the nurse assess first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ANS A
A female pt has experienced an episode of myasthenic crisis. The nurse would assess whether
the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ANS C
A pt is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this pt's care, the nurse would expect to administer what
priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
b. Furosemide (Lasix)
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 47
,c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ANS C
The nurse is caring for a pt who is postoperative following a craniotomy. When writing the plan
of care, the nurse identifies a diagnosis of deficient fluid volume r/t fluid restriction & osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - ANS B
A pt who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of
the adverse of effects of this medication, the nurse should prioritize which of the following in
the pt's plan of care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - ANS C
A nurse is admitting a pt w a severe migraine headache and a hx of acute coronary syndrome.
What migraine medication would the nurse question for this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - ANS C
The nurse is caring for a pt w increased ICP. The pt has a nursing dx of ineffective cerebral tissue
perfusion. What would be an expected outcome that the nurse would document for this
diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
@COPYRIGHT ALL RIGHTS RESERVED PAGE 3 OF 47
, c. pays attention to grooming
d. obeys commands w appropriate motor responses - ANS D
A pt exhibiting an altered LOC due to blunt-force trauma to the head is admitted to the ED. The
physician determines the pt's injury is causing increased ICP. The nurse should gauge the pt's
LOC on the results of what diagnostic tool?
a. Monro-Kellie hypothesis
b. Glasgow Coma Scale
c. Cranial nerve function
d. mental status examination - ANS B
A pt w increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the pt is now exhibiting nuchal rigidity and photophobia. The nurse
would be correct in suspecting the presence of what complication?
a. encephalitis
b. CSF leak
c. meningitis
d. catheter occlusion - ANS C
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is
contraindicated in this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - ANS B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care plan
should specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
@COPYRIGHT ALL RIGHTS RESERVED PAGE 4 OF 47
