Rasmussen Univ NUR 2243 Final Exam (pdf) | 2026/2027 | PN Skills I
Q&A | Nursing
1. The nurse is caring for a patient with a spinal cord injury at T5. The patient
reports a pounding headache and has a blood pressure of 190/100 mm Hg.
The nurse should first assess for which trigger?
A) Bladder distention
B) Pain
C) Tight clothing
D) Fecal impaction
Correct Answer: Bladder distention
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a life-
threatening condition in patients with spinal cord injuries at or above T6. The
most common trigger is bladder distention, which should be assessed and
relieved immediately. While pain, tight clothing, and fecal impaction can also
be triggers, bladder distention is the priority assessment.
2. Which of the following is the most common cause of autonomic dysreflexia
in a patient with a spinal cord injury?
A) Skin breakdown
B) Bladder distention
C) Hypotension
D) Hyperthermia
Correct Answer: Bladder distention
Rationale: Bladder distention is the most frequent trigger for autonomic
dysreflexia in patients with spinal cord injuries. The distended bladder sends
,afferent stimuli that trigger a massive sympathetic response, leading to
severe hypertension and other symptoms.
3. The nurse is caring for a patient with autonomic dysreflexia. Which finding
is consistent with this condition?
A) Hypotension and tachycardia
B) Hypertension and bradycardia
C) Hypotension and bradycardia
D) Hypertension and tachycardia
Correct Answer: Hypertension and bradycardia
Rationale: Autonomic dysreflexia is characterized by severe hypertension
(systolic BP can reach 300 mm Hg) and reflex bradycardia. The pounding
headache, diaphoresis, and nasal congestion result from the massive
sympathetic discharge above the level of injury.
4. A patient with autonomic dysreflexia has a blood pressure of 240/110 mm
Hg. Which action should the nurse take first?
A) Administer a fast-acting antihypertensive
B) Place the patient in a supine position
C) Check the patient's bladder for distention
D) Notify the healthcare provider
Correct Answer: Check the patient's bladder for distention
Rationale: The priority intervention for autonomic dysreflexia is to identify
and remove the triggering stimulus, most commonly bladder distention. The
nurse should assess for bladder distention and catheterize if needed.
,Elevating the head of the bed and administering antihypertensives are
secondary interventions.
5. The nurse is teaching a patient with a spinal cord injury about preventing
autonomic dysreflexia. Which statement by the patient indicates
understanding?
A) "I will limit my fluid intake to prevent bladder distention."
B) "I will maintain a regular bowel and bladder program."
C) "I will avoid all physical activity to prevent stimulation."
D) "I will keep the room temperature warm to prevent shivering."
Correct Answer: "I will maintain a regular bowel and bladder program."
Rationale: Maintaining a regular bowel and bladder program helps prevent
bladder distention and fecal impaction, which are common triggers for
autonomic dysreflexia. Fluid restriction is not recommended, and physical
activity should be encouraged as tolerated.
6. Which of the following best describes the transmission route for Hepatitis
A?
A) Blood transfusions
B) Fecal-oral contamination
C) Unprotected sexual contact
D) Needle sharing
Correct Answer: Fecal-oral contamination
Rationale: Hepatitis A is transmitted through the fecal-oral route, often via
contaminated food, water, or close personal contact. Contaminated seafood
and fruits/vegetables washed with contaminated water are common sources.
, 7. A patient is diagnosed with Hepatitis A. Which dietary instruction should
the nurse include in the teaching plan?
A) Avoid foods high in iron
B) Avoid foods that may have been washed in contaminated water
C) Increase intake of fatty foods
D) Limit fluid intake
Correct Answer: Avoid foods that may have been washed in contaminated
water
Rationale: Hepatitis A is transmitted via the fecal-oral route. Patients should
avoid foods that may have been washed in contaminated water, especially
when traveling. This is a key prevention strategy.
8. Which patient population is most at risk for Hepatitis B infection?
A) Young child
B) Elderly patient
C) 20-year-old with multiple sexual partners
D) Vegetarian
Correct Answer: 20-year-old with multiple sexual partners
Rationale: Hepatitis B is transmitted through blood and body fluids, including
sexual contact. Young adults with multiple sexual partners are at increased
risk. Other risk factors include IV drug use and occupational exposure.
9. A patient with Hepatitis C is prescribed ribavirin. Which teaching point is
most important for the nurse to include?
Q&A | Nursing
1. The nurse is caring for a patient with a spinal cord injury at T5. The patient
reports a pounding headache and has a blood pressure of 190/100 mm Hg.
The nurse should first assess for which trigger?
A) Bladder distention
B) Pain
C) Tight clothing
D) Fecal impaction
Correct Answer: Bladder distention
Rationale: The patient is exhibiting signs of autonomic dysreflexia, a life-
threatening condition in patients with spinal cord injuries at or above T6. The
most common trigger is bladder distention, which should be assessed and
relieved immediately. While pain, tight clothing, and fecal impaction can also
be triggers, bladder distention is the priority assessment.
2. Which of the following is the most common cause of autonomic dysreflexia
in a patient with a spinal cord injury?
A) Skin breakdown
B) Bladder distention
C) Hypotension
D) Hyperthermia
Correct Answer: Bladder distention
Rationale: Bladder distention is the most frequent trigger for autonomic
dysreflexia in patients with spinal cord injuries. The distended bladder sends
,afferent stimuli that trigger a massive sympathetic response, leading to
severe hypertension and other symptoms.
3. The nurse is caring for a patient with autonomic dysreflexia. Which finding
is consistent with this condition?
A) Hypotension and tachycardia
B) Hypertension and bradycardia
C) Hypotension and bradycardia
D) Hypertension and tachycardia
Correct Answer: Hypertension and bradycardia
Rationale: Autonomic dysreflexia is characterized by severe hypertension
(systolic BP can reach 300 mm Hg) and reflex bradycardia. The pounding
headache, diaphoresis, and nasal congestion result from the massive
sympathetic discharge above the level of injury.
4. A patient with autonomic dysreflexia has a blood pressure of 240/110 mm
Hg. Which action should the nurse take first?
A) Administer a fast-acting antihypertensive
B) Place the patient in a supine position
C) Check the patient's bladder for distention
D) Notify the healthcare provider
Correct Answer: Check the patient's bladder for distention
Rationale: The priority intervention for autonomic dysreflexia is to identify
and remove the triggering stimulus, most commonly bladder distention. The
nurse should assess for bladder distention and catheterize if needed.
,Elevating the head of the bed and administering antihypertensives are
secondary interventions.
5. The nurse is teaching a patient with a spinal cord injury about preventing
autonomic dysreflexia. Which statement by the patient indicates
understanding?
A) "I will limit my fluid intake to prevent bladder distention."
B) "I will maintain a regular bowel and bladder program."
C) "I will avoid all physical activity to prevent stimulation."
D) "I will keep the room temperature warm to prevent shivering."
Correct Answer: "I will maintain a regular bowel and bladder program."
Rationale: Maintaining a regular bowel and bladder program helps prevent
bladder distention and fecal impaction, which are common triggers for
autonomic dysreflexia. Fluid restriction is not recommended, and physical
activity should be encouraged as tolerated.
6. Which of the following best describes the transmission route for Hepatitis
A?
A) Blood transfusions
B) Fecal-oral contamination
C) Unprotected sexual contact
D) Needle sharing
Correct Answer: Fecal-oral contamination
Rationale: Hepatitis A is transmitted through the fecal-oral route, often via
contaminated food, water, or close personal contact. Contaminated seafood
and fruits/vegetables washed with contaminated water are common sources.
, 7. A patient is diagnosed with Hepatitis A. Which dietary instruction should
the nurse include in the teaching plan?
A) Avoid foods high in iron
B) Avoid foods that may have been washed in contaminated water
C) Increase intake of fatty foods
D) Limit fluid intake
Correct Answer: Avoid foods that may have been washed in contaminated
water
Rationale: Hepatitis A is transmitted via the fecal-oral route. Patients should
avoid foods that may have been washed in contaminated water, especially
when traveling. This is a key prevention strategy.
8. Which patient population is most at risk for Hepatitis B infection?
A) Young child
B) Elderly patient
C) 20-year-old with multiple sexual partners
D) Vegetarian
Correct Answer: 20-year-old with multiple sexual partners
Rationale: Hepatitis B is transmitted through blood and body fluids, including
sexual contact. Young adults with multiple sexual partners are at increased
risk. Other risk factors include IV drug use and occupational exposure.
9. A patient with Hepatitis C is prescribed ribavirin. Which teaching point is
most important for the nurse to include?
