NSG 3800 Exam 4 V1 | NSG 3800 Nursing Practice – Adult Health II |
Actual Q&A with Rationale (NSG3800 Exam 4) | Galen
1. A patient is admitted with a diagnosis of SIADH. Which laboratory finding should the nurse
anticipate?
A. Urine specific gravity 1.001
B. Serum osmolarity 310 mOsm/kg
C. Serum sodium 120 mEq/L
D. Serum potassium 5.5 mEq/L
Answer: C
Rationale: SIADH results in excessive water retention which dilutes serum electrolytes,
leading to hyponatremia. A serum sodium of 120 mEq/L is a classic finding of dilutional
hyponatremia. The nurse must monitor for neurological changes associated with this low
sodium level.
2. A nurse is caring for a patient with Diabetes Insipidus (DI). Which clinical manifestation is
expected?
A. Weight gain and edema
B. High urine specific gravity
C. Excessive thirst and polyuria
D. Bradycardia and hypertension
Answer: C
Rationale: Diabetes Insipidus is characterized by a deficiency in ADH, leading to the
excretion of large volumes of dilute urine. Patients typically experience polydipsia
(excessive thirst) as the body attempts to compensate for fluid loss. Failure to replace these
fluids can lead to severe dehydration and hypovolemic shock.
3. Which assessment finding indicates a patient is progressing toward Cushing’s Triad?
A. Tachycardia, tachypnea, and hypotension
B. Tachycardia, hypertension, and narrowed pulse pressure
C. Hypotension, bradycardia, and Cheyne-Stokes respirations
D. Bradycardia, irregular respirations, and widened pulse pressure
Answer: D
,Rationale: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) indicating
brainstem compression. It consists of systolic hypertension with a widened pulse pressure,
bradycardia, and irregular respiratory patterns. This finding is a medical emergency that
requires immediate intervention to prevent herniation.
4. A patient with a head injury has a Glasgow Coma Scale (GCS) score of 7. What is the
priority nursing action?
A. Prepare for endotracheal intubation
B. Assess pupil reaction to light
C. Monitor urine output every hour
D. Administer IV pain medication
Answer: A
Rationale: A GCS score of 8 or less indicates a severe brain injury and usually requires
airway protection. The nurse must prioritize the airway to ensure adequate oxygenation
and ventilation. Preparing for intubation is the safest action to prevent respiratory failure
or aspiration.
5. A patient is receiving Mannitol for increased ICP. Which monitor finding suggests the
medication is effective?
A. Decreased urine output
B. Increased intracranial pressure
C. Decreased intracranial pressure
D. Increased serum osmolarity
Answer: C
Rationale: Mannitol is an osmotic diuretic used to pull fluid from the brain tissue into the
vascular space. A successful outcome is demonstrated by a reduction in intracranial
pressure. The nurse should also monitor for increased urine output as a systemic effect of
the drug.
6. A patient with a T6 spinal cord injury reports a sudden, severe headache and has a BP of
190/100. What is the first action?
A. Administer antihypertensive medication
B. Notify the physician immediately
C. Check for bladder distention
D. Place the patient in a sitting position
Answer: D
, Rationale: Autonomic Dysreflexia is a life-threatening condition in spinal cord injuries
above T6. The immediate priority is to sit the patient upright to lower blood pressure via
orthostatic effect. After positioning, the nurse should investigate and remove the triggering
stimulus, such as a full bladder.
7. A patient presents with Addisonian Crisis. Which electrolyte imbalance is most likely?
A. Hypokalemia and hypernatremia
B. Hyperkalemia and hyponatremia
C. Hypercalcemia and hypomagnesemia
D. Hypocalcemia and hypernatremia
Answer: B
Rationale: Addisonian crisis involves a severe lack of cortisol and aldosterone. Lack of
aldosterone leads to potassium retention (hyperkalemia) and sodium loss (hyponatremia).
These imbalances can lead to cardiac arrhythmias and vascular collapse if not treated with
steroids and fluids.
8. Which physical characteristic is typical of a patient with Cushing’s Syndrome?
A. Hyperpigmentation of the skin
B. Thin, fragile skin with bruising
C. Weight loss and muscle hypertrophy
D. Increased exercise tolerance
Answer: B
Rationale: Cushing’s syndrome results from excessive glucocorticoids, which cause protein
wasting. This wasting leads to thin, fragile skin, easy bruising, and purple striae on the
abdomen. Other features include a moon face, buffalo hump, and truncal obesity.
9. A nurse is assessing a patient for a suspected stroke. Which tool is most appropriate for a
rapid assessment of stroke symptoms?
A. GCS Scale
B. NIH Stroke Scale
C. Braden Scale
D. Morse Fall Scale
Answer: B
Rationale: The NIH Stroke Scale (NIHSS) is the gold standard for assessing the severity of a
stroke. It evaluates level of consciousness, visual fields, motor function, and language. This
standardized tool helps determine the eligibility for fibrinolytic therapy like tPA.
Actual Q&A with Rationale (NSG3800 Exam 4) | Galen
1. A patient is admitted with a diagnosis of SIADH. Which laboratory finding should the nurse
anticipate?
A. Urine specific gravity 1.001
B. Serum osmolarity 310 mOsm/kg
C. Serum sodium 120 mEq/L
D. Serum potassium 5.5 mEq/L
Answer: C
Rationale: SIADH results in excessive water retention which dilutes serum electrolytes,
leading to hyponatremia. A serum sodium of 120 mEq/L is a classic finding of dilutional
hyponatremia. The nurse must monitor for neurological changes associated with this low
sodium level.
2. A nurse is caring for a patient with Diabetes Insipidus (DI). Which clinical manifestation is
expected?
A. Weight gain and edema
B. High urine specific gravity
C. Excessive thirst and polyuria
D. Bradycardia and hypertension
Answer: C
Rationale: Diabetes Insipidus is characterized by a deficiency in ADH, leading to the
excretion of large volumes of dilute urine. Patients typically experience polydipsia
(excessive thirst) as the body attempts to compensate for fluid loss. Failure to replace these
fluids can lead to severe dehydration and hypovolemic shock.
3. Which assessment finding indicates a patient is progressing toward Cushing’s Triad?
A. Tachycardia, tachypnea, and hypotension
B. Tachycardia, hypertension, and narrowed pulse pressure
C. Hypotension, bradycardia, and Cheyne-Stokes respirations
D. Bradycardia, irregular respirations, and widened pulse pressure
Answer: D
,Rationale: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) indicating
brainstem compression. It consists of systolic hypertension with a widened pulse pressure,
bradycardia, and irregular respiratory patterns. This finding is a medical emergency that
requires immediate intervention to prevent herniation.
4. A patient with a head injury has a Glasgow Coma Scale (GCS) score of 7. What is the
priority nursing action?
A. Prepare for endotracheal intubation
B. Assess pupil reaction to light
C. Monitor urine output every hour
D. Administer IV pain medication
Answer: A
Rationale: A GCS score of 8 or less indicates a severe brain injury and usually requires
airway protection. The nurse must prioritize the airway to ensure adequate oxygenation
and ventilation. Preparing for intubation is the safest action to prevent respiratory failure
or aspiration.
5. A patient is receiving Mannitol for increased ICP. Which monitor finding suggests the
medication is effective?
A. Decreased urine output
B. Increased intracranial pressure
C. Decreased intracranial pressure
D. Increased serum osmolarity
Answer: C
Rationale: Mannitol is an osmotic diuretic used to pull fluid from the brain tissue into the
vascular space. A successful outcome is demonstrated by a reduction in intracranial
pressure. The nurse should also monitor for increased urine output as a systemic effect of
the drug.
6. A patient with a T6 spinal cord injury reports a sudden, severe headache and has a BP of
190/100. What is the first action?
A. Administer antihypertensive medication
B. Notify the physician immediately
C. Check for bladder distention
D. Place the patient in a sitting position
Answer: D
, Rationale: Autonomic Dysreflexia is a life-threatening condition in spinal cord injuries
above T6. The immediate priority is to sit the patient upright to lower blood pressure via
orthostatic effect. After positioning, the nurse should investigate and remove the triggering
stimulus, such as a full bladder.
7. A patient presents with Addisonian Crisis. Which electrolyte imbalance is most likely?
A. Hypokalemia and hypernatremia
B. Hyperkalemia and hyponatremia
C. Hypercalcemia and hypomagnesemia
D. Hypocalcemia and hypernatremia
Answer: B
Rationale: Addisonian crisis involves a severe lack of cortisol and aldosterone. Lack of
aldosterone leads to potassium retention (hyperkalemia) and sodium loss (hyponatremia).
These imbalances can lead to cardiac arrhythmias and vascular collapse if not treated with
steroids and fluids.
8. Which physical characteristic is typical of a patient with Cushing’s Syndrome?
A. Hyperpigmentation of the skin
B. Thin, fragile skin with bruising
C. Weight loss and muscle hypertrophy
D. Increased exercise tolerance
Answer: B
Rationale: Cushing’s syndrome results from excessive glucocorticoids, which cause protein
wasting. This wasting leads to thin, fragile skin, easy bruising, and purple striae on the
abdomen. Other features include a moon face, buffalo hump, and truncal obesity.
9. A nurse is assessing a patient for a suspected stroke. Which tool is most appropriate for a
rapid assessment of stroke symptoms?
A. GCS Scale
B. NIH Stroke Scale
C. Braden Scale
D. Morse Fall Scale
Answer: B
Rationale: The NIH Stroke Scale (NIHSS) is the gold standard for assessing the severity of a
stroke. It evaluates level of consciousness, visual fields, motor function, and language. This
standardized tool helps determine the eligibility for fibrinolytic therapy like tPA.
