NSG 4100 (AHIII) Exam 4 Testbank
The pt w fibromyalgia is suffering from pain 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 - CORRECT
ANSWER-B, D, E
The nurse caring for a client w a head injury
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 - CORRECT ANSWER-A, C, D
,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
- CORRECT ANSWER-C
The critical care nurse is caring for a client 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 - CORRECT
ANSWER-B
,The nurse is caring for clients in the ED. 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 - CORRECT ANSWER-A
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 - CORRECT ANSWER-C
A pt is being admitted to the neurologic 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) - CORRECT
ANSWER-C
The nurse is caring for a pt who is 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 -
CORRECT ANSWER-B
A pt who has been on long-term phenytoin
(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 - CORRECT
ANSWER-C
The pt w fibromyalgia is suffering from pain 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 - CORRECT
ANSWER-B, D, E
The nurse caring for a client w a head injury
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 - CORRECT ANSWER-A, C, D
,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
- CORRECT ANSWER-C
The critical care nurse is caring for a client 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 - CORRECT
ANSWER-B
,The nurse is caring for clients in the ED. 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 - CORRECT ANSWER-A
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 - CORRECT ANSWER-C
A pt is being admitted to the neurologic 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) - CORRECT
ANSWER-C
The nurse is caring for a pt who is 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 -
CORRECT ANSWER-B
A pt who has been on long-term phenytoin
(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 - CORRECT
ANSWER-C
