NSG 4100 (AHIII) Exam 4 Testbank
Questions and Correct Answers
Question 1
The nurse for a pt in a persistent vegetative state is regularly assessing for potential
complications. Complications of neurologic dysfunction for which the nurse should
assess include which of the following? Select all that apply:
a. contractures
b. hemorrhage
c. pressure ulcers
d. venous thromboembolism
e. pneumonia
Correct Answer
A, C, D, E
Question 2
Match tx with its corresponding condition:
Atropine Sulfate
Correct Answer
Neurogenic Shock
Question 3
A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson
into the ED. The child is not breathing, and the grandfather states the boy was stung
by a bee in a nearby park while they were waiting for the boys mother to get off work.
Which of the following would lead the nurse to suspect that the boy is experiencing
anaphylactic shock?
a. rapid onset of acute hypertension
b. rapid onset of respiratory distress
c. rapid onset of neurologic compensation
d. rapid onset of cardiac arrest
Correct Answer
B
Page 1 of 101
,Question 4
The nurse in the ED is caring for a pt recently admitted w a likely MI. The nurse
understands that the pt's heart is pumping an inadequate supply of oxygen to the
tissues. For what health problem should the nurse assess?
a. dysrhythmias
b. increase in BP
c. increase in HR
d. decrease in oxygen demands
Correct Answer
A
Question 5
A nurse is developing a care plan for a patient with a partial-thickness burn, and
determines that an appropriate goal is to maintain position of joints in alignment.
What is the best rationale for this intervention?
A) To prevent neuropathies
B) To prevent wound breakdown
C) To prevent contractures
D) To prevent heterotopic ossification
Correct Answer
c
Question 6
A pt is admitted to the neurologic ICU w a spinal cord injury. In writing the pt's care
plan, the nurse specifies that contractures can be best prevented by what action?
a. reposting pt q2hr
b. initiating ROM as soon as the pt initiates
c. initiating ROM exercises as soon as possible after injury
d. perfuming ROM exercises one a day
Correct Answer
C
Page 2 of 101
,Question 7
An ED nurse has just received a call from EMS that they are transporting a 17 y/o man
who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most
common cause of this type of injury is what?
a. sports-related injuries
b. acts of violence
c. injuries due to a fall
d. motor vehicle accidents
Correct Answer
D
Question 8
The ICU nurse is caring for a patient in neurogenic shock following an overdose of
antianxiety medication. When assessing this patient, the nurse should recognize what
characteristic of neurogenic shock?
a. HTN
b. cool, moist skin
c. bradycardia
d. signs of sympathetic stimulation
Correct Answer
C
Question 9
The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to be
ordered to reduce the edema surrounding the tumor?
a. solumedrol
b. dextromethorphan
c. dexamethasone
d. furosemide
Correct Answer
C
Page 3 of 101
, Question 10
A nurse is planning the care of a 28y/o woman hospitalized w a diagnosis of
myasthenia gravis. What approach would be most appropriate for the care and
scheduling of diagnostic procedures for this pt?
a. all at one time, to provide a longer rest period
b. before meals, to stimulate her appetite
c. in the morning, w frequent rest periods
c. before bedtime, to promote rest
Correct Answer
C
Question 11
A pt w a T12 is in spinal shock. The nurse will expect to observe what assessment
finding?
a. absence of reflexes along w flaccid extremities
b. positive Babinskis reflex along w spastic extremities
c. hyperreflexia along w spastic extremities
d. spasticity of all 4 extremities
Correct Answer
A
Question 12
A pt has been admitted to the ICU after being recently diagnosed w an aneurysm and
the pt's admission orders include specific aneurysm precautions. What nursing action
will the nurse incorporate into the pt's plan of care?
a. elevate the HOB to 45 degrees
b. maintain the pt on complete bed rest
c. administer enemas when the pt is constipated
d. avoid use of thigh-high elastic compression stockings
Correct Answer
B
Page 4 of 101
Questions and Correct Answers
Question 1
The nurse for a pt in a persistent vegetative state is regularly assessing for potential
complications. Complications of neurologic dysfunction for which the nurse should
assess include which of the following? Select all that apply:
a. contractures
b. hemorrhage
c. pressure ulcers
d. venous thromboembolism
e. pneumonia
Correct Answer
A, C, D, E
Question 2
Match tx with its corresponding condition:
Atropine Sulfate
Correct Answer
Neurogenic Shock
Question 3
A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson
into the ED. The child is not breathing, and the grandfather states the boy was stung
by a bee in a nearby park while they were waiting for the boys mother to get off work.
Which of the following would lead the nurse to suspect that the boy is experiencing
anaphylactic shock?
a. rapid onset of acute hypertension
b. rapid onset of respiratory distress
c. rapid onset of neurologic compensation
d. rapid onset of cardiac arrest
Correct Answer
B
Page 1 of 101
,Question 4
The nurse in the ED is caring for a pt recently admitted w a likely MI. The nurse
understands that the pt's heart is pumping an inadequate supply of oxygen to the
tissues. For what health problem should the nurse assess?
a. dysrhythmias
b. increase in BP
c. increase in HR
d. decrease in oxygen demands
Correct Answer
A
Question 5
A nurse is developing a care plan for a patient with a partial-thickness burn, and
determines that an appropriate goal is to maintain position of joints in alignment.
What is the best rationale for this intervention?
A) To prevent neuropathies
B) To prevent wound breakdown
C) To prevent contractures
D) To prevent heterotopic ossification
Correct Answer
c
Question 6
A pt is admitted to the neurologic ICU w a spinal cord injury. In writing the pt's care
plan, the nurse specifies that contractures can be best prevented by what action?
a. reposting pt q2hr
b. initiating ROM as soon as the pt initiates
c. initiating ROM exercises as soon as possible after injury
d. perfuming ROM exercises one a day
Correct Answer
C
Page 2 of 101
,Question 7
An ED nurse has just received a call from EMS that they are transporting a 17 y/o man
who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most
common cause of this type of injury is what?
a. sports-related injuries
b. acts of violence
c. injuries due to a fall
d. motor vehicle accidents
Correct Answer
D
Question 8
The ICU nurse is caring for a patient in neurogenic shock following an overdose of
antianxiety medication. When assessing this patient, the nurse should recognize what
characteristic of neurogenic shock?
a. HTN
b. cool, moist skin
c. bradycardia
d. signs of sympathetic stimulation
Correct Answer
C
Question 9
The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to be
ordered to reduce the edema surrounding the tumor?
a. solumedrol
b. dextromethorphan
c. dexamethasone
d. furosemide
Correct Answer
C
Page 3 of 101
, Question 10
A nurse is planning the care of a 28y/o woman hospitalized w a diagnosis of
myasthenia gravis. What approach would be most appropriate for the care and
scheduling of diagnostic procedures for this pt?
a. all at one time, to provide a longer rest period
b. before meals, to stimulate her appetite
c. in the morning, w frequent rest periods
c. before bedtime, to promote rest
Correct Answer
C
Question 11
A pt w a T12 is in spinal shock. The nurse will expect to observe what assessment
finding?
a. absence of reflexes along w flaccid extremities
b. positive Babinskis reflex along w spastic extremities
c. hyperreflexia along w spastic extremities
d. spasticity of all 4 extremities
Correct Answer
A
Question 12
A pt has been admitted to the ICU after being recently diagnosed w an aneurysm and
the pt's admission orders include specific aneurysm precautions. What nursing action
will the nurse incorporate into the pt's plan of care?
a. elevate the HOB to 45 degrees
b. maintain the pt on complete bed rest
c. administer enemas when the pt is constipated
d. avoid use of thigh-high elastic compression stockings
Correct Answer
B
Page 4 of 101
