NUR 6121 Exam 4 V2 | NUR 6121
Advanced Nursing II | Q&A with Rationale
(NUR6121 Exam 4) | William Paterson
University
1. A patient is admitted with suspected Diabetic Ketoacidosis (DKA). Which laboratory finding
is most diagnostic of this condition over Hyperosmolar Hyperglycemic Nonketotic Syndrome
(HHNS)?
A. Blood glucose level of 500 mg/dL
B. Serum osmolarity greater than 350 mOsm/L
C. Presence of serum ketones and metabolic acidosis
D. Bicarbonate level of 24 mEq/L
Answer: C
Rationale: DKA is characterized by the presence of ketones and a low pH, indicating
metabolic acidosis. In contrast, HHNS typically presents with significantly higher glucose
levels and higher osmolarity without significant ketoacidosis. The nurse must differentiate
these to prioritize insulin and fluid resuscitation protocols appropriately.
2. Which clinical manifestation would the nurse expect to observe in a patient diagnosed with
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?
A. Hyponatremia and fluid volume excess
,B. Severe dehydration and hypernatremia
C. Increased urinary output and dilute urine
D. Weight loss and postural hypotension
Answer: A
Rationale: SIADH involves excessive ADH secretion, leading to water retention and
dilutional hyponatremia. The nurse should monitor for signs of fluid overload such as
weight gain and crackles. Management focuses on fluid restriction and monitoring serum
sodium levels to prevent neurological complications.
3. A patient with a head injury develops Diabetes Insipidus (DI). What is the primary nursing
intervention for this patient?
A. Restricting oral fluid intake to 1000 mL/day
B. Encouraging a low-protein diet
C. Monitoring for signs of fluid volume excess
D. Administering desmopressin (DDAVP) as prescribed
Answer: D
Rationale: Diabetes Insipidus is caused by a deficiency of ADH, leading to massive polyuria
and potential hypovolemic shock. Desmopressin is a synthetic ADH replacement that helps
concentrate urine and reduce output. The nurse must also monitor strict intake/output and
serum electrolytes.
, 4. A patient presents with a Glasgow Coma Scale (GCS) score of 7. How should the nurse
interpret this finding?
A. The patient is fully alert and oriented
B. The patient has a severe head injury and may require intubation
C. The patient has a moderate head injury
D. The patient is in a light coma but stable
Answer: B
Rationale: A GCS score of 8 or less generally indicates a severe head injury and a comatose
state. At a score of 7, airway protection is a priority because the patient may lack a cough or
gag reflex. The nurse should prepare for potential emergency airway management and
intensive monitoring.
5. A patient with a T6 spinal cord injury reports a sudden, pounding headache and is found to
have a blood pressure of 210/110 mmHg. What is the nurse’s first action?
A. Administer an antihypertensive medication
B. Notify the healthcare provider immediately
C. Check for bladder distension or fecal impaction
D. Raise the head of the bed to 90 degrees
Answer: D
Advanced Nursing II | Q&A with Rationale
(NUR6121 Exam 4) | William Paterson
University
1. A patient is admitted with suspected Diabetic Ketoacidosis (DKA). Which laboratory finding
is most diagnostic of this condition over Hyperosmolar Hyperglycemic Nonketotic Syndrome
(HHNS)?
A. Blood glucose level of 500 mg/dL
B. Serum osmolarity greater than 350 mOsm/L
C. Presence of serum ketones and metabolic acidosis
D. Bicarbonate level of 24 mEq/L
Answer: C
Rationale: DKA is characterized by the presence of ketones and a low pH, indicating
metabolic acidosis. In contrast, HHNS typically presents with significantly higher glucose
levels and higher osmolarity without significant ketoacidosis. The nurse must differentiate
these to prioritize insulin and fluid resuscitation protocols appropriately.
2. Which clinical manifestation would the nurse expect to observe in a patient diagnosed with
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?
A. Hyponatremia and fluid volume excess
,B. Severe dehydration and hypernatremia
C. Increased urinary output and dilute urine
D. Weight loss and postural hypotension
Answer: A
Rationale: SIADH involves excessive ADH secretion, leading to water retention and
dilutional hyponatremia. The nurse should monitor for signs of fluid overload such as
weight gain and crackles. Management focuses on fluid restriction and monitoring serum
sodium levels to prevent neurological complications.
3. A patient with a head injury develops Diabetes Insipidus (DI). What is the primary nursing
intervention for this patient?
A. Restricting oral fluid intake to 1000 mL/day
B. Encouraging a low-protein diet
C. Monitoring for signs of fluid volume excess
D. Administering desmopressin (DDAVP) as prescribed
Answer: D
Rationale: Diabetes Insipidus is caused by a deficiency of ADH, leading to massive polyuria
and potential hypovolemic shock. Desmopressin is a synthetic ADH replacement that helps
concentrate urine and reduce output. The nurse must also monitor strict intake/output and
serum electrolytes.
, 4. A patient presents with a Glasgow Coma Scale (GCS) score of 7. How should the nurse
interpret this finding?
A. The patient is fully alert and oriented
B. The patient has a severe head injury and may require intubation
C. The patient has a moderate head injury
D. The patient is in a light coma but stable
Answer: B
Rationale: A GCS score of 8 or less generally indicates a severe head injury and a comatose
state. At a score of 7, airway protection is a priority because the patient may lack a cough or
gag reflex. The nurse should prepare for potential emergency airway management and
intensive monitoring.
5. A patient with a T6 spinal cord injury reports a sudden, pounding headache and is found to
have a blood pressure of 210/110 mmHg. What is the nurse’s first action?
A. Administer an antihypertensive medication
B. Notify the healthcare provider immediately
C. Check for bladder distension or fecal impaction
D. Raise the head of the bed to 90 degrees
Answer: D
