NSG 4100 (AHIII) Exam 4 (ACTUAL 2025/2026)
QUESTIONS AND VERIFIED ANSWERS.
A pt w a C5 spinal cord injury is tetraplegic. After being
The pt w fibromyalgia is suffering from pain at 12 of the 18 moved out of the ICU, the pt c/o sever throbbing HA. What
identification sites, including the neck & upper back & knees. should the nurse do first?
The pt also reports non-refreshing sleep, depression, & being a. check the pt's indwelling urinary catheter for kinks to
anxious when dealing w multiple tasks. The nurse should ensure patecny
teach this pt about what treatments? Select all that apply:
b. lower the HOB to improve perfusion
a. Minimal aerobic exercise
c. administer analgesia
b. Relaxation strategy (biofeedback)
d. reassure the pt that headaches are expected after spinal cord
c. Anti-seizure during phenytoin injuries
d. Serotonin reuptake inhibitor (e.g. sertraline) A
e. Establish a regular sleep pattern
B, D, E
A pt is admitted to the neurologic ICU w a spinal cord injury.
When assessing the pt the nurse notes there is a sudden
depression fo reflex activity in the spinal cord below the level
of injury. What should the nurse suspect?
A pt w a head injury had been increasingly agitated & the
a. epidural hemorrhage
nurse has consequently identifies a risk for injury. What is the
nurses best intervention for preventing injury? b. hypertensive emergency
a. restrain the pt as ordered c. spinal shock
b. administer opioids PRN as ordered d. hypovolemia
c. arrange for friends & family members to sit w the pt C
d. pad the side rails of the pt's bed
D
,An elderly woman found w a head injury on the floor of her b. level of consciousness
home is subsequently admitted to the neurologic ICU. What is c. cognitive ability
the best rationale for the following physician orders: elevate
the HOB; keep the head in neutral alignment w no neck d. sensory involvement
flexion or head rotation; avoid sharp hip flexion? B
a. to decrease cerebral arterial pressure
b. to avoid impeding venous outflow
c. to prevent flexion contractures The nurse is caring for a pt who is rapidly progressing toward
d. to prevent aspiration of stomach contents brain death. The nurse should be aware of what cardinal signs
of brain death? Select all that apply.
B
a. absence of pain response
b. apnea
c. coma
A pt w a T12 is in spinal shock. The nurse will expect to
observe what assessment finding? d. absence of brain stem reflexes
a. absence of reflexes along w flaccid extremities e. absence of deep tendon reflexes
b. positive Babinskis reflex along w spastic extremities B, C, D
c. hyperreflexia along w spastic extremities
d. spasticity of all 4 extremities
A Following a SCI a pt is placed in halo traction. While
performing pin site care, the nurse notes that one of the
traction pins has become detached. The nurse would be
correct in implementing what priority nursing action?
A nurse is reviewing the trend of a pt's scores on the Glasgow a. compete the pin site care to decrease risk of infection
Coma Scale (GCS). This allows the nurse to gauge what b. notify the neurosurgeon of the occurrence
aspect of the pt's status?
c. stabilize the head in a lateral position
a. reflex activity
,d. reattach the pin to prevent further head trauma
B A neurologic flow chart is often used to document the care of
a pt w a traumatic brain injury. At what point in the pt's care
should the nurse begin to use a neurologic flow chart?
a. when the pt's condition begins to deteriorate
The ED is notifies that a 6 y/o is in transit w a suspected brain
injury after being struck by a car. The child is unresponsive at b. as soon as the initial assessment is made
this time, but vital signs are within acceptable limits. What c. at the beginning of each shift
will be the primary goal of initial therapy? d. when there is a clinically significant change in the pt's
a. promote adequate circulation condition
b. treating the child's increased ICP B
c. assessing secondary brain injury
d. preserving brain homeostasis
D The nurse planning the care of a pt w head injuries is
addressing the pt's nursing dx of sleep deprivation. What
action should the nurse implement?
a. administer a benzodiapine at bedtime each night
An 82 y/o man is admitted for observation after a fall. Due to
his age, the nurse knows that the pt is at increased risk for b. do not disturb the pt between 2200 & 0600
what complication of his injury? c. cluster overnight nursing activities to minima disturbances
a. hematoma d. ensure that the pt does not sleep during the day
b. skull fracture C
c. embolus
d. stroke
A The nurse has implemented interventions amend at facilitating
family coping in the care of a pt w a traumatic brain injury.
How can the nurse best facilitate family coping?
, a. help the family understand that the pt could've died b. obtain the players vital signs, if possible
b. empathize the importance of accepting the pt's new c. perform a rapid assessment of the players ROM
limitations d. assess the player's reflexes
c. have the members of the family plan the pt's inpatient care A
d. assist family in setting appropriate short-term goals
D
The nurse is caring for a pt whose spinal cord injury has
caused recent muscle spasticity. What medication should the
The school nurse is giving a presentation on preventing spinal nurse expect to be ordered to control this?
cord injuries (SCI). What should the nurse identify as a. Baclofen (Lioresal)
prominent risk factors for SCI? Select all that apply. b. Dexamethasone (Decadron)
a. young age c. Mannitol (Osmitrol)
b. frequent travel d. Phenobarbital (Luminal)
c. African American race A
d. male gender
e. alcohol or drug use
A, D, E The nurse is planning the care of a pt w a T1 spinal cord
injury. The nurse has identified the diagnosis of risk for
impaired skin integrity. How can the nurse best address this
risk?
The school nurse has been called to the football field where
player is immobile on the field after landing awkwardly on his a. change the patients position frequently
head during a play. While awaiting an ambulance, what action b. provide a high-protein diet
should the nurse perform? c. provide light massage at least daily
a. ensure that the player is not moved d. teach the pt deep breathing & coughing exercises
QUESTIONS AND VERIFIED ANSWERS.
A pt w a C5 spinal cord injury is tetraplegic. After being
The pt w fibromyalgia is suffering from pain at 12 of the 18 moved out of the ICU, the pt c/o sever throbbing HA. What
identification sites, including the neck & upper back & knees. should the nurse do first?
The pt also reports non-refreshing sleep, depression, & being a. check the pt's indwelling urinary catheter for kinks to
anxious when dealing w multiple tasks. The nurse should ensure patecny
teach this pt about what treatments? Select all that apply:
b. lower the HOB to improve perfusion
a. Minimal aerobic exercise
c. administer analgesia
b. Relaxation strategy (biofeedback)
d. reassure the pt that headaches are expected after spinal cord
c. Anti-seizure during phenytoin injuries
d. Serotonin reuptake inhibitor (e.g. sertraline) A
e. Establish a regular sleep pattern
B, D, E
A pt is admitted to the neurologic ICU w a spinal cord injury.
When assessing the pt the nurse notes there is a sudden
depression fo reflex activity in the spinal cord below the level
of injury. What should the nurse suspect?
A pt w a head injury had been increasingly agitated & the
a. epidural hemorrhage
nurse has consequently identifies a risk for injury. What is the
nurses best intervention for preventing injury? b. hypertensive emergency
a. restrain the pt as ordered c. spinal shock
b. administer opioids PRN as ordered d. hypovolemia
c. arrange for friends & family members to sit w the pt C
d. pad the side rails of the pt's bed
D
,An elderly woman found w a head injury on the floor of her b. level of consciousness
home is subsequently admitted to the neurologic ICU. What is c. cognitive ability
the best rationale for the following physician orders: elevate
the HOB; keep the head in neutral alignment w no neck d. sensory involvement
flexion or head rotation; avoid sharp hip flexion? B
a. to decrease cerebral arterial pressure
b. to avoid impeding venous outflow
c. to prevent flexion contractures The nurse is caring for a pt who is rapidly progressing toward
d. to prevent aspiration of stomach contents brain death. The nurse should be aware of what cardinal signs
of brain death? Select all that apply.
B
a. absence of pain response
b. apnea
c. coma
A pt w a T12 is in spinal shock. The nurse will expect to
observe what assessment finding? d. absence of brain stem reflexes
a. absence of reflexes along w flaccid extremities e. absence of deep tendon reflexes
b. positive Babinskis reflex along w spastic extremities B, C, D
c. hyperreflexia along w spastic extremities
d. spasticity of all 4 extremities
A Following a SCI a pt is placed in halo traction. While
performing pin site care, the nurse notes that one of the
traction pins has become detached. The nurse would be
correct in implementing what priority nursing action?
A nurse is reviewing the trend of a pt's scores on the Glasgow a. compete the pin site care to decrease risk of infection
Coma Scale (GCS). This allows the nurse to gauge what b. notify the neurosurgeon of the occurrence
aspect of the pt's status?
c. stabilize the head in a lateral position
a. reflex activity
,d. reattach the pin to prevent further head trauma
B A neurologic flow chart is often used to document the care of
a pt w a traumatic brain injury. At what point in the pt's care
should the nurse begin to use a neurologic flow chart?
a. when the pt's condition begins to deteriorate
The ED is notifies that a 6 y/o is in transit w a suspected brain
injury after being struck by a car. The child is unresponsive at b. as soon as the initial assessment is made
this time, but vital signs are within acceptable limits. What c. at the beginning of each shift
will be the primary goal of initial therapy? d. when there is a clinically significant change in the pt's
a. promote adequate circulation condition
b. treating the child's increased ICP B
c. assessing secondary brain injury
d. preserving brain homeostasis
D The nurse planning the care of a pt w head injuries is
addressing the pt's nursing dx of sleep deprivation. What
action should the nurse implement?
a. administer a benzodiapine at bedtime each night
An 82 y/o man is admitted for observation after a fall. Due to
his age, the nurse knows that the pt is at increased risk for b. do not disturb the pt between 2200 & 0600
what complication of his injury? c. cluster overnight nursing activities to minima disturbances
a. hematoma d. ensure that the pt does not sleep during the day
b. skull fracture C
c. embolus
d. stroke
A The nurse has implemented interventions amend at facilitating
family coping in the care of a pt w a traumatic brain injury.
How can the nurse best facilitate family coping?
, a. help the family understand that the pt could've died b. obtain the players vital signs, if possible
b. empathize the importance of accepting the pt's new c. perform a rapid assessment of the players ROM
limitations d. assess the player's reflexes
c. have the members of the family plan the pt's inpatient care A
d. assist family in setting appropriate short-term goals
D
The nurse is caring for a pt whose spinal cord injury has
caused recent muscle spasticity. What medication should the
The school nurse is giving a presentation on preventing spinal nurse expect to be ordered to control this?
cord injuries (SCI). What should the nurse identify as a. Baclofen (Lioresal)
prominent risk factors for SCI? Select all that apply. b. Dexamethasone (Decadron)
a. young age c. Mannitol (Osmitrol)
b. frequent travel d. Phenobarbital (Luminal)
c. African American race A
d. male gender
e. alcohol or drug use
A, D, E The nurse is planning the care of a pt w a T1 spinal cord
injury. The nurse has identified the diagnosis of risk for
impaired skin integrity. How can the nurse best address this
risk?
The school nurse has been called to the football field where
player is immobile on the field after landing awkwardly on his a. change the patients position frequently
head during a play. While awaiting an ambulance, what action b. provide a high-protein diet
should the nurse perform? c. provide light massage at least daily
a. ensure that the player is not moved d. teach the pt deep breathing & coughing exercises
