NUR 417 Final Exam V3 | NUR 417 Nursing Care of
the Adult II | Actual Q&A with Rationale (NUR417
Final Exam) | Concordia
1. A patient is admitted with suspected Septic Shock. Which of the following findings would
the nurse expect during the early (hyperdynamic) phase? Select all that apply.
A. Increased cardiac output
B. Skin that is cool, pale, and clammy
C. Decreased systemic vascular resistance (SVR)
D. Tachycardia and bounding pulses
E. Oliguria with dark, concentrated urine
Correct Answer: A, C, D
Explanation: In the early phase of septic shock, the body compensates with a
hyperdynamic state characterized by high cardiac output and low systemic vascular
resistance due to massive vasodilation. The skin is typically warm and flushed rather than
cool and pale. These manifestations reflect the inflammatory response to the infectious
process before compensatory mechanisms fail.
2. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg.
Which nursing intervention is most appropriate to help decrease ICP?
A. Encourage the patient to perform isometric exercises.
,B. Keep the room brightly lit and the television on for stimulation.
C. Suction the patient for 30 seconds every hour to keep the airway clear.
D. Maintain the head of the bed at 30 degrees with the neck in a neutral position.
Correct Answer: D
Explanation: Elevating the head of the bed to 30 degrees promotes venous drainage from
the cranial vault, which directly helps to lower ICP. Neutral neck alignment prevents
obstruction of the jugular veins, further facilitating drainage. Isometric exercises and
excessive suctioning are avoided as they can significantly increase intrathoracic and
intracranial pressure.
3. A patient is in the compensatory stage of shock. Which clinical manifestation does the
nurse expect to observe?
A. Narrowed pulse pressure
B. Decreased heart rate
C. Metabolic alkalosis
D. Increased urinary output
Correct Answer: A
Explanation: During the compensatory stage of shock, the body uses the renin-
angiotensin-aldosterone system and catecholamine release to maintain perfusion. A
narrowed pulse pressure occurs as the diastolic pressure rises due to systemic
,vasoconstriction while systolic pressure remains stable or slightly drops. The heart rate
typically increases, and urine output decreases as the kidneys conserve water.
4. A patient with a T4 spinal cord injury suddenly develops a severe headache, a blood
pressure of 210/110 mmHg, and bradycardia. What is the priority nursing action?
A. Administer an ordered antihypertensive medication.
B. Place the patient in a supine position immediately.
C. Check for bladder distension or fecal impaction.
D. Notify the physician to order a STAT head CT scan.
Correct Answer: C
Explanation: These symptoms are classic signs of autonomic dysreflexia, a life-threatening
emergency in patients with spinal cord injuries at or above T6. The most common triggers
are bladder distension or bowel impaction, which cause an exaggerated sympathetic
response. The priority is to identify and remove the noxious stimulus while sitting the
patient upright to lower blood pressure.
5. Which hemodynamic parameter is most indicative of Cardiogenic Shock?
A. Decreased Central Venous Pressure (CVP)
B. Increased Cardiac Index (CI)
C. Increased Pulmonary Artery Wedge Pressure (PAWP)
D. Decreased Systemic Vascular Resistance (SVR)
, Correct Answer: C
Explanation: In cardiogenic shock, the heart fails to pump effectively, leading to blood
backing up into the pulmonary circulation. This results in an elevated PAWP (wedge
pressure) and CVP. Cardiac output is low, and SVR is typically increased as the body
attempts to compensate for the low blood pressure.
6. A nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) on
mechanical ventilation. The ventilator’s high-pressure alarm sounds. What are potential
causes? Select all that apply.
A. Patient biting the endotracheal tube
B. Accumulation of secretions in the airway
C. Disconnection of the ventilator tubing
D. Pneumothorax
E. Kinking of the ventilator circuit
Correct Answer: A, B, D, E
Explanation: High-pressure alarms are triggered when the ventilator encounters
resistance during breath delivery. Common causes include biting the tube, secretions,
decreased lung compliance (like ARDS or pneumothorax), and physical obstructions like
kinks. Disconnection would cause a low-pressure alarm due to the loss of a closed system.
the Adult II | Actual Q&A with Rationale (NUR417
Final Exam) | Concordia
1. A patient is admitted with suspected Septic Shock. Which of the following findings would
the nurse expect during the early (hyperdynamic) phase? Select all that apply.
A. Increased cardiac output
B. Skin that is cool, pale, and clammy
C. Decreased systemic vascular resistance (SVR)
D. Tachycardia and bounding pulses
E. Oliguria with dark, concentrated urine
Correct Answer: A, C, D
Explanation: In the early phase of septic shock, the body compensates with a
hyperdynamic state characterized by high cardiac output and low systemic vascular
resistance due to massive vasodilation. The skin is typically warm and flushed rather than
cool and pale. These manifestations reflect the inflammatory response to the infectious
process before compensatory mechanisms fail.
2. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg.
Which nursing intervention is most appropriate to help decrease ICP?
A. Encourage the patient to perform isometric exercises.
,B. Keep the room brightly lit and the television on for stimulation.
C. Suction the patient for 30 seconds every hour to keep the airway clear.
D. Maintain the head of the bed at 30 degrees with the neck in a neutral position.
Correct Answer: D
Explanation: Elevating the head of the bed to 30 degrees promotes venous drainage from
the cranial vault, which directly helps to lower ICP. Neutral neck alignment prevents
obstruction of the jugular veins, further facilitating drainage. Isometric exercises and
excessive suctioning are avoided as they can significantly increase intrathoracic and
intracranial pressure.
3. A patient is in the compensatory stage of shock. Which clinical manifestation does the
nurse expect to observe?
A. Narrowed pulse pressure
B. Decreased heart rate
C. Metabolic alkalosis
D. Increased urinary output
Correct Answer: A
Explanation: During the compensatory stage of shock, the body uses the renin-
angiotensin-aldosterone system and catecholamine release to maintain perfusion. A
narrowed pulse pressure occurs as the diastolic pressure rises due to systemic
,vasoconstriction while systolic pressure remains stable or slightly drops. The heart rate
typically increases, and urine output decreases as the kidneys conserve water.
4. A patient with a T4 spinal cord injury suddenly develops a severe headache, a blood
pressure of 210/110 mmHg, and bradycardia. What is the priority nursing action?
A. Administer an ordered antihypertensive medication.
B. Place the patient in a supine position immediately.
C. Check for bladder distension or fecal impaction.
D. Notify the physician to order a STAT head CT scan.
Correct Answer: C
Explanation: These symptoms are classic signs of autonomic dysreflexia, a life-threatening
emergency in patients with spinal cord injuries at or above T6. The most common triggers
are bladder distension or bowel impaction, which cause an exaggerated sympathetic
response. The priority is to identify and remove the noxious stimulus while sitting the
patient upright to lower blood pressure.
5. Which hemodynamic parameter is most indicative of Cardiogenic Shock?
A. Decreased Central Venous Pressure (CVP)
B. Increased Cardiac Index (CI)
C. Increased Pulmonary Artery Wedge Pressure (PAWP)
D. Decreased Systemic Vascular Resistance (SVR)
, Correct Answer: C
Explanation: In cardiogenic shock, the heart fails to pump effectively, leading to blood
backing up into the pulmonary circulation. This results in an elevated PAWP (wedge
pressure) and CVP. Cardiac output is low, and SVR is typically increased as the body
attempts to compensate for the low blood pressure.
6. A nurse is caring for a patient with Acute Respiratory Distress Syndrome (ARDS) on
mechanical ventilation. The ventilator’s high-pressure alarm sounds. What are potential
causes? Select all that apply.
A. Patient biting the endotracheal tube
B. Accumulation of secretions in the airway
C. Disconnection of the ventilator tubing
D. Pneumothorax
E. Kinking of the ventilator circuit
Correct Answer: A, B, D, E
Explanation: High-pressure alarms are triggered when the ventilator encounters
resistance during breath delivery. Common causes include biting the tube, secretions,
decreased lung compliance (like ARDS or pneumothorax), and physical obstructions like
kinks. Disconnection would cause a low-pressure alarm due to the loss of a closed system.
