4
Advanced Medical-Surgical Nursing: NURS 476
Exam III REAL EXAM QUESTIONS & VERIFIED
ANSWERS - PASS FIRST ATTEMPT
GUARANTEED UPDATED QUESTIONS AND
100% ACCURATE ANSWERS | HIGH-LEVEL EXIT
EXAM
Question 1
A nurse is caring for Bradly, a 24-year-old male who sustained a T5 spinal cord injury. Bradly
suddenly reports a severe, throbbing headache, has a blood pressure of $183/95\text{ mm
Hg}$, and a heart rate of $51\text{ bpm}$. He is flushed and sweating profusely across his face,
neck, and upper torso, but his lower extremities are pale. He states he is seeing spots and says,
"I feel the doom coming." What clinical condition should the nurse immediately suspect?
• a) Spinal shock
• b) Neurogenic shock
• c) Autonomic dysreflexia
• d) Hypovolemic shock
Correct Answer: c
Rationale: Autonomic dysreflexia (AD) is a life-threatening emergency that occurs in patients
with spinal cord injuries at or above the T6 level. It is triggered by noxious stimuli below the
lesion (such as bladder distension or fecal impaction), causing uninhibited sympathetic
discharge. This results in severe hypertension, a compensatory bradycardia (due to vagal
stimulation), profuse sweating and flushing above the level of the injury, and pale, cool skin
below the level of the injury due to vasoconstriction.
Question 2
A nurse is assessing a patient who has developed autonomic dysreflexia (AD). Which clinical
manifestations are characteristically associated with this condition? (Select all that apply)
• a) Sudden drop in blood pressure accompanied by severe tachycardia
,4
• b) Profuse sweating and flushness above the level of the spinal lesion
• c) Visual disturbances, such as seeing spots
• d) Severe, throbbing headache
• e) Pale, cool skin below the level of the spinal lesion
Correct Answer: b, c, d, e
Rationale: Autonomic dysreflexia presents with severe, sudden hypertension (not hypotension)
and bradycardia (not tachycardia) due to the body's baroreceptor response attempting to
counteract the massive sympathetic surge. The other signs—sweating/flushing above the lesion
(b), blurred vision or spots (c), a pounding headache caused by severe hypertension (d), and
pallor below the injury site (e)—are hallmark diagnostic findings.
Question 3
A client who sustained a recent cervical spinal cord injury reports having a throbbing headache
and feeling flushed. The client's blood pressure is $190/110\text{ mm Hg}$. What is the nurse's
priority action at this time?
• a) Perform an immediate bedside bladder assessment
• b) Insert an indwelling urinary catheter
• c) Place the patient in an upright sitting position
• d) Turn on a fan to cool the patient down
Correct Answer: c
Rationale: The immediate first step when autonomic dysreflexia is suspected is to sit the patient
upright (high-Fowler's position) to induce orthostatic pooling of blood and lower the
dangerously high intracranial and systemic blood pressure. After sitting the patient up, the
nurse should systematically assess for and remove the triggering cause (e.g., checking for
catheter kinks, fecal impaction, or tight clothing) and notify the healthcare provider.
Question 4
A nurse is caring for a patient who sustained an acute spinal cord injury at the C3 level. Which
assessment parameter is the highest priority for the nurse to evaluate first?
• a) Circulatory status and capillary refill
• b) Workload and adequacy of breathing
,4
• c) Level of consciousness
• d) Peripheral sensory perception
Correct Answer: b
Rationale: Following the ABC (Airway, Breathing, Circulation) priority framework, breathing is
the critical concern for an injury at this level. Spinal nerves C3 through C5 innervate the phrenic
nerve, which controls the diaphragm. An injury at C3 puts the patient at extreme risk for
immediate respiratory arrest or insufficiency, necessitating priority monitoring of respiratory
effort and ventilatory status.
Question 5
A nurse is caring for a patient 30 hours following a T4 spinal cord injury. Upon assessment, the
patient's oxygen saturation is 84%, heart rate is $45\text{ bpm}$, and they exhibit confusion
and dizziness. The nurse has already secured a patent airway, applied a face mask at $6\text{
L/min}$ to address oxygenation, and stabilized the spine. What is the next priority assessment?
• a) Suction the patient's upper airway
• b) Assess the patient's level of consciousness (LOC)
• c) Assess the patient's blood pressure
• d) Assess the patient's deep tendon reflexes (DTRs)
Correct Answer: c
Rationale: The patient is exhibiting hallmark signs of neurogenic shock, a form of distributive
shock common in injuries above T6. It causes a loss of sympathetic tone, leading to massive
vasodilation, profound hypotension, and bradycardia. Because airway and breathing have
already been stabilized via the oxygen mask, assessing circulation (specifically blood pressure) is
the immediate next priority to determine perfusion needs, such as IV fluids or vasopressors.
Question 6
A nurse is evaluating sensory perception by assessing dermatomes in a patient who sustained a
C7 spinal cord injury 1 hour ago. Which approach or finding is incorrect or abnormal regarding
this assessment?
• a) The nurse begins the assessment at the area of normal sensation and moves down
toward the area where sensation is lost.
• b) The nurse notifies the healthcare provider immediately when a new loss of sensation
deviates from the baseline.
, 4
• c) All deep tendon reflexes (DTRs) are completely absent below the level of the injury.
• d) The patient has a total loss of voluntary bowel and bladder control.
Correct Answer: a
Rationale: Dermatome assessments should be performed from bottom to top (moving from the
area of absent sensation upward until normal sensation is felt). Moving from an area of altered
sensation to intact sensation provides a more accurate mapping of the injury level. Options b, c,
and d are expected findings: absent reflexes signify spinal shock (which occurs immediately
after injury), and loss of bowel/bladder control is standard for cervical spinal injuries.
Question 7
A nurse is caring for Bradly, who developed autonomic dysreflexia. The nurse has placed the
patient in a high-Fowler's position, unkinked the urinary catheter to remove the noxious
stimulus, and notified the provider. Which medication should the nurse anticipate administering
to manage Bradly's severe hypertension?
• a) Atropine sulfate
• b) Dextran
• c) Dopamine
• d) Nifedipine
Correct Answer: d
Rationale: If non-pharmacological interventions (sitting the patient up and removing the
stimulus) do not rapidly resolve the hypertensive crisis of autonomic dysreflexia, an
antihypertensive medication is indicated. Nifedipine (a calcium channel blocker) or nitropaste is
commonly anticipated. Atropine increases heart rate but does not lower blood pressure;
Dextran (a plasma expander) and Dopamine (a vasopressor) are used to raise blood pressure in
neurogenic shock, which would be contraindicated here.
Question 8
Which secondary complication is considered the primary, most dangerous priority problem that
can develop in a patient experiencing prolonged, uncontrolled autonomic dysreflexia?
• a) Deep vein thrombosis
• b) Hypertensive ischemic stroke
• c) Irreversible paralytic ileus
Advanced Medical-Surgical Nursing: NURS 476
Exam III REAL EXAM QUESTIONS & VERIFIED
ANSWERS - PASS FIRST ATTEMPT
GUARANTEED UPDATED QUESTIONS AND
100% ACCURATE ANSWERS | HIGH-LEVEL EXIT
EXAM
Question 1
A nurse is caring for Bradly, a 24-year-old male who sustained a T5 spinal cord injury. Bradly
suddenly reports a severe, throbbing headache, has a blood pressure of $183/95\text{ mm
Hg}$, and a heart rate of $51\text{ bpm}$. He is flushed and sweating profusely across his face,
neck, and upper torso, but his lower extremities are pale. He states he is seeing spots and says,
"I feel the doom coming." What clinical condition should the nurse immediately suspect?
• a) Spinal shock
• b) Neurogenic shock
• c) Autonomic dysreflexia
• d) Hypovolemic shock
Correct Answer: c
Rationale: Autonomic dysreflexia (AD) is a life-threatening emergency that occurs in patients
with spinal cord injuries at or above the T6 level. It is triggered by noxious stimuli below the
lesion (such as bladder distension or fecal impaction), causing uninhibited sympathetic
discharge. This results in severe hypertension, a compensatory bradycardia (due to vagal
stimulation), profuse sweating and flushing above the level of the injury, and pale, cool skin
below the level of the injury due to vasoconstriction.
Question 2
A nurse is assessing a patient who has developed autonomic dysreflexia (AD). Which clinical
manifestations are characteristically associated with this condition? (Select all that apply)
• a) Sudden drop in blood pressure accompanied by severe tachycardia
,4
• b) Profuse sweating and flushness above the level of the spinal lesion
• c) Visual disturbances, such as seeing spots
• d) Severe, throbbing headache
• e) Pale, cool skin below the level of the spinal lesion
Correct Answer: b, c, d, e
Rationale: Autonomic dysreflexia presents with severe, sudden hypertension (not hypotension)
and bradycardia (not tachycardia) due to the body's baroreceptor response attempting to
counteract the massive sympathetic surge. The other signs—sweating/flushing above the lesion
(b), blurred vision or spots (c), a pounding headache caused by severe hypertension (d), and
pallor below the injury site (e)—are hallmark diagnostic findings.
Question 3
A client who sustained a recent cervical spinal cord injury reports having a throbbing headache
and feeling flushed. The client's blood pressure is $190/110\text{ mm Hg}$. What is the nurse's
priority action at this time?
• a) Perform an immediate bedside bladder assessment
• b) Insert an indwelling urinary catheter
• c) Place the patient in an upright sitting position
• d) Turn on a fan to cool the patient down
Correct Answer: c
Rationale: The immediate first step when autonomic dysreflexia is suspected is to sit the patient
upright (high-Fowler's position) to induce orthostatic pooling of blood and lower the
dangerously high intracranial and systemic blood pressure. After sitting the patient up, the
nurse should systematically assess for and remove the triggering cause (e.g., checking for
catheter kinks, fecal impaction, or tight clothing) and notify the healthcare provider.
Question 4
A nurse is caring for a patient who sustained an acute spinal cord injury at the C3 level. Which
assessment parameter is the highest priority for the nurse to evaluate first?
• a) Circulatory status and capillary refill
• b) Workload and adequacy of breathing
,4
• c) Level of consciousness
• d) Peripheral sensory perception
Correct Answer: b
Rationale: Following the ABC (Airway, Breathing, Circulation) priority framework, breathing is
the critical concern for an injury at this level. Spinal nerves C3 through C5 innervate the phrenic
nerve, which controls the diaphragm. An injury at C3 puts the patient at extreme risk for
immediate respiratory arrest or insufficiency, necessitating priority monitoring of respiratory
effort and ventilatory status.
Question 5
A nurse is caring for a patient 30 hours following a T4 spinal cord injury. Upon assessment, the
patient's oxygen saturation is 84%, heart rate is $45\text{ bpm}$, and they exhibit confusion
and dizziness. The nurse has already secured a patent airway, applied a face mask at $6\text{
L/min}$ to address oxygenation, and stabilized the spine. What is the next priority assessment?
• a) Suction the patient's upper airway
• b) Assess the patient's level of consciousness (LOC)
• c) Assess the patient's blood pressure
• d) Assess the patient's deep tendon reflexes (DTRs)
Correct Answer: c
Rationale: The patient is exhibiting hallmark signs of neurogenic shock, a form of distributive
shock common in injuries above T6. It causes a loss of sympathetic tone, leading to massive
vasodilation, profound hypotension, and bradycardia. Because airway and breathing have
already been stabilized via the oxygen mask, assessing circulation (specifically blood pressure) is
the immediate next priority to determine perfusion needs, such as IV fluids or vasopressors.
Question 6
A nurse is evaluating sensory perception by assessing dermatomes in a patient who sustained a
C7 spinal cord injury 1 hour ago. Which approach or finding is incorrect or abnormal regarding
this assessment?
• a) The nurse begins the assessment at the area of normal sensation and moves down
toward the area where sensation is lost.
• b) The nurse notifies the healthcare provider immediately when a new loss of sensation
deviates from the baseline.
, 4
• c) All deep tendon reflexes (DTRs) are completely absent below the level of the injury.
• d) The patient has a total loss of voluntary bowel and bladder control.
Correct Answer: a
Rationale: Dermatome assessments should be performed from bottom to top (moving from the
area of absent sensation upward until normal sensation is felt). Moving from an area of altered
sensation to intact sensation provides a more accurate mapping of the injury level. Options b, c,
and d are expected findings: absent reflexes signify spinal shock (which occurs immediately
after injury), and loss of bowel/bladder control is standard for cervical spinal injuries.
Question 7
A nurse is caring for Bradly, who developed autonomic dysreflexia. The nurse has placed the
patient in a high-Fowler's position, unkinked the urinary catheter to remove the noxious
stimulus, and notified the provider. Which medication should the nurse anticipate administering
to manage Bradly's severe hypertension?
• a) Atropine sulfate
• b) Dextran
• c) Dopamine
• d) Nifedipine
Correct Answer: d
Rationale: If non-pharmacological interventions (sitting the patient up and removing the
stimulus) do not rapidly resolve the hypertensive crisis of autonomic dysreflexia, an
antihypertensive medication is indicated. Nifedipine (a calcium channel blocker) or nitropaste is
commonly anticipated. Atropine increases heart rate but does not lower blood pressure;
Dextran (a plasma expander) and Dopamine (a vasopressor) are used to raise blood pressure in
neurogenic shock, which would be contraindicated here.
Question 8
Which secondary complication is considered the primary, most dangerous priority problem that
can develop in a patient experiencing prolonged, uncontrolled autonomic dysreflexia?
• a) Deep vein thrombosis
• b) Hypertensive ischemic stroke
• c) Irreversible paralytic ileus
