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NSG 4100 (AHIII) Exam 4 Testbank Exam QUESTIONS AND VERIFIED ANSWERS

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NSG 4100 (AHIII) Exam 4 Testbank Exam QUESTIONS AND VERIFIED ANSWERS NSG 4100 (AHIII) Exam 4 Testbank Exam QUESTIONS AND VERIFIED ANSWERS NSG 4100 (AHIII) Exam 4 Testbank Exam QUESTIONS AND VERIFIED ANSWERS

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NSG 4100 (AHIII) Exam 4 Testbank

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The pt w fibromyalgia is suffering from pain B, D, E
at 12 of the 18 identification sites, including
the neck & upper back & knees. The pt also
reports non-refreshing sleep, depression, &
being anxious when dealing w multiple
tasks. The nurse should teach this pt about
what treatments? Select all that apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g.
sertraline)
e. Establish a regular sleep pattern

The nurse caring for a client w a head injury A, C, D
would recognize which assessment finding
as early signs of increased ICP? Select all
that apply:
a. Kussmaul breathing
b. Projectile vomiting
c. Weakness in one extremity
d. Headache not aggravated by movement
of straining
e. Decreased urine output
f. Papilledema

,A nurse caring for a client diagnosed to C
have head injury. Which of the following
situations needs intervention by the nurse?
a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one
hour in the afternoon and 3 hours in the
evening
d. The head of bed is elevated at 30
degree angle

The critical care nurse is caring for a client B
w a head injury secondary to a motorcycle
accident who, on morning rounds, is
responsive to painful stimulus and assumes
decorticate posturing. Two hours later,
which data would warrant immediate
intervention by the nurse?
a. The client has purposeful movement
when the nurse rubs the sternum
b. The client extends the upper and lower
extremities in response to painful stimuli
c. The client is aimlessly thrashing in the
bed when a noxious stimuli is applied
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The nurse is caring for clients in the ED. A
Which client should the nurse assess first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in
the postictal state
c. The client diagnosed w R/O encephalitis
who has a headache
d. The client w multiple sclerosis who has
scanning speech

A female pt has experienced an episode of C
myasthenic crisis. The nurse would assess
whether the pt has precipitating factors
such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods

A pt is being admitted to the neurologic C
ICU following an acute head injury that has
resulted in cerebral edema. When planning
this pt's care, the nurse would expect to
administer what priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
b. Furosemide (Lasix)
c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone)

, The nurse is caring for a pt who is B
postoperative following a craniotomy.
When writing the plan of care, the nurse
identifies a diagnosis of deficient fluid
volume r/t fluid restriction & osmotic
diuretic use. What would be an appropriate
intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values

A pt who has been on long-term phenytoin C
(Dilantin) therapy is admitted to the unit. In
light of the adverse of effects of this
medication, the nurse should prioritize
which of the following in the pt's plan of
care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered

A nurse is admitting a pt w a severe C
migraine headache and a hx of acute
coronary syndrome. What migraine
medication would the nurse question for
this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig)

The nurse is caring for a pt w increased D
ICP. The pt has a nursing dx of ineffective
cerebral tissue perfusion. What would be
an expected outcome that the nurse would
document for this diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
c. pays attention to grooming
d. obeys commands w appropriate motor
responses

A pt exhibiting an altered LOC due to B
blunt-force trauma to the head is admitted
to the ED. The physician determines the pt's
injury is causing increased ICP. The nurse
should gauge the pt's LOC on the results of
what diagnostic tool?
a. Monro-Kellie hypothesis
b. Glasgow Coma Scale
c. Cranial nerve function
d. mental status examination

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