NSG 4100 EXAM 4
1. The nurse is caring for a client with a head/brain trauma. Which finding requires follow-up?
A. 300 mL output
B. 100 mL output
C. 50 mL output
D. 75 mL output
2. The nurse is caring for a client who experienced a traumatic brain injury 12 hours ago. The client is
unconscious. Which finding should the nurse report to the provider?
A. Pupil size of 3–4 mm
B. Increase in pupil size from 7 mm to 10 mm
C. Equal and reactive pupils
D. Stable level of consciousness
3. The nurse is caring for a client with a closed head injury who is receiving mechanical ventilation and
is at risk for increased intracranial pressure (ICP). Which intervention should the nurse implement?
A. Keep the client flat in bed
B. Position the client in Trendelenburg
C. Elevate the head of the bed 30–45°
D. Encourage frequent coughing
,4. The nurse is caring for a client with a spinal cord injury who is wearing a halo device. The family
reports that they can insert two fingers between the halo vest and the client's chest. How should the
nurse respond?
A. The halo is too loose and must be tightened immediately
B. The halo should be removed
C. This is normal
D. The client should be placed in traction
5. The nurse is caring for a client with a cerebral hemorrhage who has become increasingly agitated.
What should the nurse recognize?
A. Decreased ICP
B. Improved neurologic function
C. Increased intracranial pressure (ICP)
D. Normal expected behavior
6. The nurse is caring for a client with Guillain-Barré syndrome who intermittently coughs up
moderate amounts of secretions. How should the nurse interpret this finding?
A. Indicates immediate respiratory failure
B. Indicates worsening paralysis
C. Normal finding
D. Indicates increased ICP
7. The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who requests that
resuscitation be withheld. How should the nurse respond?
, A. The request should be denied
B. The family must make the decision
C. The client's wishes should be respected
D. Resuscitation must always be performed
8. The nurse is caring for a client 2 hours after a craniotomy. Which finding requires the nurse to notify
the provider?
A. Alert and oriented
B. Mild incisional pain
C. Increase in drainage/output to 200 mL
D. Stable vital signs
9. The nurse is caring for a client who had a craniotomy for removal of a brain tumor. Which finding
should be reported to the primary healthcare provider?
A. Mild headache
B. Incisional discomfort
C. Postnasal drip
D. Mild fatigue
10. The nurse is attending a conference about cryptococcal meningitis. Which statement indicates
correct understanding?
A. It is primarily associated with diabetes
B. It is primarily associated with hypertension
C. It is primarily associated with asthma
D. It is associated with AIDS/immunosuppression
1. The nurse is caring for a client with a head/brain trauma. Which finding requires follow-up?
A. 300 mL output
B. 100 mL output
C. 50 mL output
D. 75 mL output
2. The nurse is caring for a client who experienced a traumatic brain injury 12 hours ago. The client is
unconscious. Which finding should the nurse report to the provider?
A. Pupil size of 3–4 mm
B. Increase in pupil size from 7 mm to 10 mm
C. Equal and reactive pupils
D. Stable level of consciousness
3. The nurse is caring for a client with a closed head injury who is receiving mechanical ventilation and
is at risk for increased intracranial pressure (ICP). Which intervention should the nurse implement?
A. Keep the client flat in bed
B. Position the client in Trendelenburg
C. Elevate the head of the bed 30–45°
D. Encourage frequent coughing
,4. The nurse is caring for a client with a spinal cord injury who is wearing a halo device. The family
reports that they can insert two fingers between the halo vest and the client's chest. How should the
nurse respond?
A. The halo is too loose and must be tightened immediately
B. The halo should be removed
C. This is normal
D. The client should be placed in traction
5. The nurse is caring for a client with a cerebral hemorrhage who has become increasingly agitated.
What should the nurse recognize?
A. Decreased ICP
B. Improved neurologic function
C. Increased intracranial pressure (ICP)
D. Normal expected behavior
6. The nurse is caring for a client with Guillain-Barré syndrome who intermittently coughs up
moderate amounts of secretions. How should the nurse interpret this finding?
A. Indicates immediate respiratory failure
B. Indicates worsening paralysis
C. Normal finding
D. Indicates increased ICP
7. The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who requests that
resuscitation be withheld. How should the nurse respond?
, A. The request should be denied
B. The family must make the decision
C. The client's wishes should be respected
D. Resuscitation must always be performed
8. The nurse is caring for a client 2 hours after a craniotomy. Which finding requires the nurse to notify
the provider?
A. Alert and oriented
B. Mild incisional pain
C. Increase in drainage/output to 200 mL
D. Stable vital signs
9. The nurse is caring for a client who had a craniotomy for removal of a brain tumor. Which finding
should be reported to the primary healthcare provider?
A. Mild headache
B. Incisional discomfort
C. Postnasal drip
D. Mild fatigue
10. The nurse is attending a conference about cryptococcal meningitis. Which statement indicates
correct understanding?
A. It is primarily associated with diabetes
B. It is primarily associated with hypertension
C. It is primarily associated with asthma
D. It is associated with AIDS/immunosuppression
