Verified
NSG 4100
Exam 4
Final
Exam!!
Neurological & Critical Care Concepts
Page|1
,1) A 19 y/o woman was admitted to ICU following high-velocity MVA in which she
sustained a severe closed head injury. Nurse noticed she has been producing a large
amount of urine for the past 3 hrs and is becoming tachycardic and hypotensive. The
nurse knows that this client needs to be closely monitored for developing which
condition?
A) Cushing syndrome, which is treated w/ intermittent doses of corticoids
B) DI, which is treated w/ antidiuretic hormone (Vasopressin)
C) SIADH, which is create w/ ADH
D) DM, which is treated w/ basal analog insulin
Correct Answer: B
Head trauma can cause Diabetes Insipidus from decreased ADH secretion, presenting with
polyuria, polydipsia, tachycardia, and hypotension. Treatment involves ADH replacement
(Vasopressin/Desmopressin) and fluid replacement.
2) Client w/ pituitary tumor developed SIADH. Which intervention should the nurse
implement?
A) Assess for dehydration and monitor BG level
B) Assess for n/v & weigh daily
C) Monitor potassium level & encourage fluid intake
D) Administer vasopressin IV and conduct fluid deprivation test
Correct Answer: B
SIADH causes fluid retention, weight gain, and hyponatremia. Monitoring for
nausea/vomiting (signs of hyponatremia) and daily weights (to track fluid retention) are
essential. Fluid intake should be restricted, not encouraged.
3) Nurse is admitting a client to the neurological ICU who is postoperative
transsphenoidal hypophysectomy. Which data warrants immediate intervention?
A) Client is alert to name but unable to tell nurse the location
B) Client has output of 2500ml since surgery and intake of 1000ml
C) Client vital signs are T 97.6F, P 88, RR 22, BP 130/
D) Client has 3cm amount of dark red drainage on turban dressing
Correct Answer: B
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, Output of 2500 mL with intake of only 1000 mL indicates significant fluid loss, possibly from
diabetes insipidus, a common complication after transsphenoidal hypophysectomy. This
requires immediate intervention.
4) A client with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU,
the pt c/o severe throbbing HA. What should the nurse do first?
A) Check the pt's indwelling urinary catheter for kinks to ensure patency
B) Lower the HOB to improve perfusion
C) Administer analgesia
D) Reassure the pt that headaches are expected after spinal cord injuries
Correct Answer: A
Severe headache in a client with a spinal cord injury above T6 suggests autonomic
dysreflexia. The priority is to identify and eliminate the triggering stimulus, most commonly
bladder distention. Checking the urinary catheter for kinks is the first action.
5) A pt w a T12 is in spinal shock. The nurse will expect to observe what assessment
finding?
A) Absence of reflexes along w/ flaccid extremities
B) Positive Babinski's reflex along w/ spastic extremities
C) Hyperreflexia along w/ spastic extremities
D) Spasticity of all 4 extremities
Correct Answer: A
Spinal shock is characterized by a sudden depression of reflex activity below the level of
injury, resulting in flaccid paralysis and absence of reflexes.
6) A nurse is reviewing the trend of a pt's scores on the Glasgow Coma Scale (GCS).
This allows the nurse to gauge what aspect of the pt's status?
A) Reflex activity
B) Level of consciousness
C) Cognitive ability
D) Sensory involvement
Correct Answer: B
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NSG 4100
Exam 4
Final
Exam!!
Neurological & Critical Care Concepts
Page|1
,1) A 19 y/o woman was admitted to ICU following high-velocity MVA in which she
sustained a severe closed head injury. Nurse noticed she has been producing a large
amount of urine for the past 3 hrs and is becoming tachycardic and hypotensive. The
nurse knows that this client needs to be closely monitored for developing which
condition?
A) Cushing syndrome, which is treated w/ intermittent doses of corticoids
B) DI, which is treated w/ antidiuretic hormone (Vasopressin)
C) SIADH, which is create w/ ADH
D) DM, which is treated w/ basal analog insulin
Correct Answer: B
Head trauma can cause Diabetes Insipidus from decreased ADH secretion, presenting with
polyuria, polydipsia, tachycardia, and hypotension. Treatment involves ADH replacement
(Vasopressin/Desmopressin) and fluid replacement.
2) Client w/ pituitary tumor developed SIADH. Which intervention should the nurse
implement?
A) Assess for dehydration and monitor BG level
B) Assess for n/v & weigh daily
C) Monitor potassium level & encourage fluid intake
D) Administer vasopressin IV and conduct fluid deprivation test
Correct Answer: B
SIADH causes fluid retention, weight gain, and hyponatremia. Monitoring for
nausea/vomiting (signs of hyponatremia) and daily weights (to track fluid retention) are
essential. Fluid intake should be restricted, not encouraged.
3) Nurse is admitting a client to the neurological ICU who is postoperative
transsphenoidal hypophysectomy. Which data warrants immediate intervention?
A) Client is alert to name but unable to tell nurse the location
B) Client has output of 2500ml since surgery and intake of 1000ml
C) Client vital signs are T 97.6F, P 88, RR 22, BP 130/
D) Client has 3cm amount of dark red drainage on turban dressing
Correct Answer: B
Page|2
, Output of 2500 mL with intake of only 1000 mL indicates significant fluid loss, possibly from
diabetes insipidus, a common complication after transsphenoidal hypophysectomy. This
requires immediate intervention.
4) A client with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU,
the pt c/o severe throbbing HA. What should the nurse do first?
A) Check the pt's indwelling urinary catheter for kinks to ensure patency
B) Lower the HOB to improve perfusion
C) Administer analgesia
D) Reassure the pt that headaches are expected after spinal cord injuries
Correct Answer: A
Severe headache in a client with a spinal cord injury above T6 suggests autonomic
dysreflexia. The priority is to identify and eliminate the triggering stimulus, most commonly
bladder distention. Checking the urinary catheter for kinks is the first action.
5) A pt w a T12 is in spinal shock. The nurse will expect to observe what assessment
finding?
A) Absence of reflexes along w/ flaccid extremities
B) Positive Babinski's reflex along w/ spastic extremities
C) Hyperreflexia along w/ spastic extremities
D) Spasticity of all 4 extremities
Correct Answer: A
Spinal shock is characterized by a sudden depression of reflex activity below the level of
injury, resulting in flaccid paralysis and absence of reflexes.
6) A nurse is reviewing the trend of a pt's scores on the Glasgow Coma Scale (GCS).
This allows the nurse to gauge what aspect of the pt's status?
A) Reflex activity
B) Level of consciousness
C) Cognitive ability
D) Sensory involvement
Correct Answer: B
Page|3
