NSG 4100 (AHIII) Exam 4 Testbank
A 69 y/o pt is brought to the ED bc a family member found him lying on the
floor disoriented and lethargic. The physician suspects bacterial meningitis &
admits the pt to the ICU. The nurse knows that risk factors for an unfavorable
outcome include what? Select all that apply:
a. BP greater than 140/90 mm Hg
b. HR greater than 120 bpm
c. older age
d. low Glasgow scale
e. lack of previous immunizations - ----ANS:B, C, D
A client recovering from head injury is participating in care. The nurse
determines that the client understands measure to prevent elevations in ICP if
the nurse observes the client doing which of the following?
a. blowing the nose
b. isometric exercise
c. coughing vigorously
d. healing during repositioning - ----ANS:D
A client w Guillain-Barre syndrome has ascending paralysis and is intubated
and receiving mechanical intubation. Which strategy should the nurse
incorporate in the plan of care to help the client cope w this illness?
a. giving the client full control over care decisions & restricting visitors
b. providing positive feedback and encouraging active ROM
c. providing info, giving positive feedback, & encouraging relaxation
d, proving IV administered sedatives, reducing distractions, & limiting visitors -
----ANS:C
A client w SCI is prone to experience autonomic dysreflexia. The nurse should
include which measures in the plan of care to minimize the risk of occurrence?
Select all that apply:
a. keep the linen wrinkle-free under the client
b. preventing unnecessary pressure on the lower limbs
c. limiting bladder cauterization to once every 12 hrs
d. turning & repositioning the client every 2 hrs
e. ensuring that the client has a bowel movement - ----ANS:A, B, D
,A clinic nurse is providing patient education prior to a patients scheduled
palliative radiotherapy to her spine. At the completion of the patient teaching,
the patient continues to ask the same questions that the nurse has already
addressed. What is the plausible conclusion that the nurse should draw from
this?
a. the pt is not listening effectively
b. the pt is noncompliant w the plan of care
c. the pt may have low intelligence quotient or a cognitive deficit
d. the pt has not achieved the desire learning outcomes - ----ANS:D
A critical care nurse is aware of similarities and differences between the
treatments for different types of shock. Which of the following interventions is
used in all types of shock?
a. agressive hypoglycemic control
b. administration of hypertonic IV fluids
c. early provision of nutritional support
d. agressive antibiotic therapy - ----ANS:C
A critical care nurse is aware of the high incidence of ventilator-associated
pneumonia (VAP) in patients who are being treated for shock. What
intervention should be specified in the patients plan of care while the patient is
ventilated?
a. performing frequent oral care
b. maintinas pt in supine position
c. suctioning pt q15mins unless contraindicated
d. administering prophylactic abx, as ordered - ----ANS:A
A critical care nurse is planning assessments in the knowledge that patients in
shock are vulnerable to developing fluid replacement complications. For what
signs and symptoms should the nurse monitor the patient? Select all that
apply.
a. hypovolemia
b. difficulty breathing
c. cardiovascular overload
d. pulmonary edema
e. hypoglycemia - ----ANS:B, C, D
A female pt has experienced an episode of 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 - ----ANS:C
A home care nurse is performing a visit to a patients home to perform wound
care following the patients hospital treatment for severe burns. While
interacting with the patient, the nurse should assess for evidence of what
complication?
A) Psychosis
B) Post-traumatic stress disorder
C) Delirium
D) Vascular dementia - ----ANS:B
A male pt presents to clinic c/o headache. The nurse notes that the pt is
guarding his neck and tells the nurse that he has stiffness in the neck area.
The nurse suspects the pt may have meningitis. What is another
well-recognized sign of this infection?
a. negative Brudzinskis sign
b. positive Kernigs sign
c. hyper patellar reflex
d. sluggish pupil reaction - ----ANS: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
b. as soon as the initial assessment is made
c. at the beginning of each shift
d. when there is a clinically significant change in the pt's condition - ----ANS:B
A nurse caring for a client diagnosed to 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 - ----ANS:C
, A nurse has reported for a shift at a busy burns and plastics unit in a large
university hospital. Which patient is most likely to have life-threatening
complications?
A) A 4-year-old scald victim burned over 24% of the body
B) A 27-year-old male burned over 36% of his body in a car accident
C) A 39-year-old female patient burned over 18% of her body
D) A 60-year-old male burned over 16% of his body in a brush fire - ----ANS:A
A nurse in the ICU is planning the care of a pt who is being treated for shock.
Which of the following statements best describes the pathophysiology of this
pt's health problem?
a. blood is shunted from vital organs to peripheral areas of the body
b. cells lack an adequate blood supply and are deprived of oxygen and
nutrients
c. circulating blood volume is decreased w a resulting change in the osmotic
pressure gradient
d. hemorrhage occurs as a result of trauma, depriving vital organs of adequate
perfusion - ----ANS:B
A nurse in the ICU receives report from the nurse in the ED about a new pt
being admitted w a neck injury he received while diving into a lake. The ED
nurse reports that his BP is 85/54, heart rate is 53 beats/min, and his skin is
warm and dry. What does the ICU nurse recognize that the pt is probably
experiencing?
a. anaphylactic shock
b. neurogenic shock
c. septic shock
d. hypovolemic shock - ----ANS:B
A nurse is admitting a pt w a severe 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) - ----ANS:C
A nurse is caring for a critically ill pt w autonomic dysreflexia. What clinical
manifestations would the nurse expect in this pt?
a. respiratory distress & projectile vomiting
A 69 y/o pt is brought to the ED bc a family member found him lying on the
floor disoriented and lethargic. The physician suspects bacterial meningitis &
admits the pt to the ICU. The nurse knows that risk factors for an unfavorable
outcome include what? Select all that apply:
a. BP greater than 140/90 mm Hg
b. HR greater than 120 bpm
c. older age
d. low Glasgow scale
e. lack of previous immunizations - ----ANS:B, C, D
A client recovering from head injury is participating in care. The nurse
determines that the client understands measure to prevent elevations in ICP if
the nurse observes the client doing which of the following?
a. blowing the nose
b. isometric exercise
c. coughing vigorously
d. healing during repositioning - ----ANS:D
A client w Guillain-Barre syndrome has ascending paralysis and is intubated
and receiving mechanical intubation. Which strategy should the nurse
incorporate in the plan of care to help the client cope w this illness?
a. giving the client full control over care decisions & restricting visitors
b. providing positive feedback and encouraging active ROM
c. providing info, giving positive feedback, & encouraging relaxation
d, proving IV administered sedatives, reducing distractions, & limiting visitors -
----ANS:C
A client w SCI is prone to experience autonomic dysreflexia. The nurse should
include which measures in the plan of care to minimize the risk of occurrence?
Select all that apply:
a. keep the linen wrinkle-free under the client
b. preventing unnecessary pressure on the lower limbs
c. limiting bladder cauterization to once every 12 hrs
d. turning & repositioning the client every 2 hrs
e. ensuring that the client has a bowel movement - ----ANS:A, B, D
,A clinic nurse is providing patient education prior to a patients scheduled
palliative radiotherapy to her spine. At the completion of the patient teaching,
the patient continues to ask the same questions that the nurse has already
addressed. What is the plausible conclusion that the nurse should draw from
this?
a. the pt is not listening effectively
b. the pt is noncompliant w the plan of care
c. the pt may have low intelligence quotient or a cognitive deficit
d. the pt has not achieved the desire learning outcomes - ----ANS:D
A critical care nurse is aware of similarities and differences between the
treatments for different types of shock. Which of the following interventions is
used in all types of shock?
a. agressive hypoglycemic control
b. administration of hypertonic IV fluids
c. early provision of nutritional support
d. agressive antibiotic therapy - ----ANS:C
A critical care nurse is aware of the high incidence of ventilator-associated
pneumonia (VAP) in patients who are being treated for shock. What
intervention should be specified in the patients plan of care while the patient is
ventilated?
a. performing frequent oral care
b. maintinas pt in supine position
c. suctioning pt q15mins unless contraindicated
d. administering prophylactic abx, as ordered - ----ANS:A
A critical care nurse is planning assessments in the knowledge that patients in
shock are vulnerable to developing fluid replacement complications. For what
signs and symptoms should the nurse monitor the patient? Select all that
apply.
a. hypovolemia
b. difficulty breathing
c. cardiovascular overload
d. pulmonary edema
e. hypoglycemia - ----ANS:B, C, D
A female pt has experienced an episode of 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 - ----ANS:C
A home care nurse is performing a visit to a patients home to perform wound
care following the patients hospital treatment for severe burns. While
interacting with the patient, the nurse should assess for evidence of what
complication?
A) Psychosis
B) Post-traumatic stress disorder
C) Delirium
D) Vascular dementia - ----ANS:B
A male pt presents to clinic c/o headache. The nurse notes that the pt is
guarding his neck and tells the nurse that he has stiffness in the neck area.
The nurse suspects the pt may have meningitis. What is another
well-recognized sign of this infection?
a. negative Brudzinskis sign
b. positive Kernigs sign
c. hyper patellar reflex
d. sluggish pupil reaction - ----ANS: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
b. as soon as the initial assessment is made
c. at the beginning of each shift
d. when there is a clinically significant change in the pt's condition - ----ANS:B
A nurse caring for a client diagnosed to 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 - ----ANS:C
, A nurse has reported for a shift at a busy burns and plastics unit in a large
university hospital. Which patient is most likely to have life-threatening
complications?
A) A 4-year-old scald victim burned over 24% of the body
B) A 27-year-old male burned over 36% of his body in a car accident
C) A 39-year-old female patient burned over 18% of her body
D) A 60-year-old male burned over 16% of his body in a brush fire - ----ANS:A
A nurse in the ICU is planning the care of a pt who is being treated for shock.
Which of the following statements best describes the pathophysiology of this
pt's health problem?
a. blood is shunted from vital organs to peripheral areas of the body
b. cells lack an adequate blood supply and are deprived of oxygen and
nutrients
c. circulating blood volume is decreased w a resulting change in the osmotic
pressure gradient
d. hemorrhage occurs as a result of trauma, depriving vital organs of adequate
perfusion - ----ANS:B
A nurse in the ICU receives report from the nurse in the ED about a new pt
being admitted w a neck injury he received while diving into a lake. The ED
nurse reports that his BP is 85/54, heart rate is 53 beats/min, and his skin is
warm and dry. What does the ICU nurse recognize that the pt is probably
experiencing?
a. anaphylactic shock
b. neurogenic shock
c. septic shock
d. hypovolemic shock - ----ANS:B
A nurse is admitting a pt w a severe 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) - ----ANS:C
A nurse is caring for a critically ill pt w autonomic dysreflexia. What clinical
manifestations would the nurse expect in this pt?
a. respiratory distress & projectile vomiting
