NUR 2571 Exam 4 Actual Exam V1 | NUR 2571 Professional Nursing II /
PN2 (NUR2571 Exam 4) | Rasmussen
1. A nurse is assessing a client with a suspected basilar skull fracture. Which of the following
findings should the nurse identify as a characteristic sign of this injury?
A. Bilateral periorbital edema and ecchymosis (Battle sign)
B. Hyperreflexia in the lower extremities
C. Elevated blood pressure with a narrowing pulse pressure
D. Clear fluid leaking from the nose that tests positive for glucose
Answer: D
Rationale: A basilar skull fracture often results in cerebrospinal fluid (CSF) leakage
through the nose or ears. The presence of glucose in clear nasal drainage is a definitive
indicator that the fluid is CSF rather than mucus. The nurse must prioritize monitoring for
signs of infection such as meningitis in these clients.
2. A client is experiencing an episode of autonomic dysreflexia. What is the nurse’s priority
action?
A. Administer an antihypertensive medication immediately
B. Assess the skin for pressure ulcers or tight clothing
C. Check the client’s bladder for distention
D. Place the client in a high-Fowler’s position
Answer: D
Rationale: Elevating the head of the bed to a high-Fowler’s position is the immediate
priority to help lower blood pressure through orthostatic changes. This condition is a
medical emergency that occurs in clients with spinal cord injuries at or above T6. After
positioning, the nurse should then investigate and remove the triggering stimulus, such as a
full bladder or impacted bowel.
3. The nurse is providing discharge education for a client who underwent a cataract
extraction. Which statement by the client indicates an understanding of the teaching?
A. I will lie on the side of the operated eye to reduce pressure.
B. I can lift objects up to 20 pounds as long as I use my legs.
C. I should call the doctor if I see flashes of light or floaters.
D. It is normal to have severe pain in the eye for the first 24 hours.
,Answer: C
Rationale: Seeing flashes of light or new floaters can indicate retinal detachment, which is
a serious complication following ocular surgery. Clients should be instructed to avoid
activities that increase intraocular pressure, such as heavy lifting or lying on the affected
side. Severe pain is not expected and should be reported immediately as it may indicate
hemorrhage or infection.
4. A client with Myasthenia Gravis is being monitored for a potential crisis. Which assessment
finding would most suggest the client is experiencing a Myasthenic Crisis rather than a
Cholinergic Crisis?
A. Generalized weakness that improves after administration of edrophonium
B. Excessive salivation and abdominal cramping
C. Muscular twitching and fasciculations
D. Pupillary constriction and hypotension
Answer: A
Rationale: A Myasthenic Crisis is caused by an insufficiency of acetylcholine, and
symptoms improve temporarily with the administration of Tensilon (edrophonium). In
contrast, a Cholinergic Crisis is caused by overmedication and will worsen or show no
improvement with Tensilon. Respiratory support is the primary concern in both types of
crises due to potential muscle failure.
5. The nurse is caring for a client with Multiple Sclerosis (MS). Which intervention is most
appropriate to help the client manage chronic fatigue?
A. Encourage the client to complete all tasks in the morning when energy is highest.
B. Advise the client to take hot showers to relax muscles before starting the day.
C. Instruct the client to avoid all physical exercise to conserve energy.
D. Recommend frequent rest periods and pacing of daily activities.
Answer: D
Rationale: Pacing activities and taking frequent rest breaks are essential for managing the
debilitating fatigue associated with MS. Heat exposure, such as hot showers, can actually
exacerbate MS symptoms and should be avoided. Exercise is encouraged but should be
moderate and performed in a cool environment to maintain muscle function without
causing exhaustion.
6. A client is admitted with a Glasgow Coma Scale (GCS) score of 7. How should the nurse
interpret this finding?
A. The client has a severe brain injury and requires airway protection.
B. The client is in a moderate coma state.
, C. The client is awake but disoriented.
D. The client is exhibiting localized response to painful stimuli.
Answer: A
Rationale: A GCS score of 8 or less is generally used as the threshold to define a coma and
indicates a severe brain injury. At a score of 7, the client likely lacks the ability to protect
their own airway, necessitating intubation. This scale assesses eye-opening, verbal
response, and motor response to determine neurological status.
7. A nurse is caring for a client with increased intracranial pressure (ICP) following a head
injury. Which position is most appropriate for this client?
A. Supine with the head of the bed flat
B. Side-lying with the knees flexed to the chest
C. Trendelenburg position to improve cerebral perfusion
D. Head of the bed elevated 30 to 45 degrees with head midline
Answer: D
Rationale: Elevating the head of the bed facilitates venous drainage from the brain, which
helps reduce intracranial pressure. Maintaining the head in a midline position prevents
obstruction of the jugular veins. Extreme hip flexion or a flat position can impede drainage
and should be avoided in clients with elevated ICP.
8. Which clinical manifestation should the nurse expect to find in a client diagnosed with
Diabetes Insipidus (DI)?
A. High urine specific gravity and fluid volume excess
B. Excessive thirst and high urine output with low specific gravity
C. Low serum sodium and peripheral edema
D. Weight gain and concentrated dark urine
Answer: B
Rationale: Diabetes Insipidus is characterized by a deficiency in antidiuretic hormone
(ADH), leading to the excretion of large amounts of dilute urine. This results in polyuria,
polydipsia, and a low urine specific gravity (usually below 1.005). The nurse must monitor
for dehydration and hypernatremia as the body loses free water.
9. A client with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) is being treated.
Which of the following provider orders should the nurse clarify?
A. Fluid restriction of 800 mL per day
B. Administration of 0.45% Sodium Chloride IV at 125 mL/hr
PN2 (NUR2571 Exam 4) | Rasmussen
1. A nurse is assessing a client with a suspected basilar skull fracture. Which of the following
findings should the nurse identify as a characteristic sign of this injury?
A. Bilateral periorbital edema and ecchymosis (Battle sign)
B. Hyperreflexia in the lower extremities
C. Elevated blood pressure with a narrowing pulse pressure
D. Clear fluid leaking from the nose that tests positive for glucose
Answer: D
Rationale: A basilar skull fracture often results in cerebrospinal fluid (CSF) leakage
through the nose or ears. The presence of glucose in clear nasal drainage is a definitive
indicator that the fluid is CSF rather than mucus. The nurse must prioritize monitoring for
signs of infection such as meningitis in these clients.
2. A client is experiencing an episode of autonomic dysreflexia. What is the nurse’s priority
action?
A. Administer an antihypertensive medication immediately
B. Assess the skin for pressure ulcers or tight clothing
C. Check the client’s bladder for distention
D. Place the client in a high-Fowler’s position
Answer: D
Rationale: Elevating the head of the bed to a high-Fowler’s position is the immediate
priority to help lower blood pressure through orthostatic changes. This condition is a
medical emergency that occurs in clients with spinal cord injuries at or above T6. After
positioning, the nurse should then investigate and remove the triggering stimulus, such as a
full bladder or impacted bowel.
3. The nurse is providing discharge education for a client who underwent a cataract
extraction. Which statement by the client indicates an understanding of the teaching?
A. I will lie on the side of the operated eye to reduce pressure.
B. I can lift objects up to 20 pounds as long as I use my legs.
C. I should call the doctor if I see flashes of light or floaters.
D. It is normal to have severe pain in the eye for the first 24 hours.
,Answer: C
Rationale: Seeing flashes of light or new floaters can indicate retinal detachment, which is
a serious complication following ocular surgery. Clients should be instructed to avoid
activities that increase intraocular pressure, such as heavy lifting or lying on the affected
side. Severe pain is not expected and should be reported immediately as it may indicate
hemorrhage or infection.
4. A client with Myasthenia Gravis is being monitored for a potential crisis. Which assessment
finding would most suggest the client is experiencing a Myasthenic Crisis rather than a
Cholinergic Crisis?
A. Generalized weakness that improves after administration of edrophonium
B. Excessive salivation and abdominal cramping
C. Muscular twitching and fasciculations
D. Pupillary constriction and hypotension
Answer: A
Rationale: A Myasthenic Crisis is caused by an insufficiency of acetylcholine, and
symptoms improve temporarily with the administration of Tensilon (edrophonium). In
contrast, a Cholinergic Crisis is caused by overmedication and will worsen or show no
improvement with Tensilon. Respiratory support is the primary concern in both types of
crises due to potential muscle failure.
5. The nurse is caring for a client with Multiple Sclerosis (MS). Which intervention is most
appropriate to help the client manage chronic fatigue?
A. Encourage the client to complete all tasks in the morning when energy is highest.
B. Advise the client to take hot showers to relax muscles before starting the day.
C. Instruct the client to avoid all physical exercise to conserve energy.
D. Recommend frequent rest periods and pacing of daily activities.
Answer: D
Rationale: Pacing activities and taking frequent rest breaks are essential for managing the
debilitating fatigue associated with MS. Heat exposure, such as hot showers, can actually
exacerbate MS symptoms and should be avoided. Exercise is encouraged but should be
moderate and performed in a cool environment to maintain muscle function without
causing exhaustion.
6. A client is admitted with a Glasgow Coma Scale (GCS) score of 7. How should the nurse
interpret this finding?
A. The client has a severe brain injury and requires airway protection.
B. The client is in a moderate coma state.
, C. The client is awake but disoriented.
D. The client is exhibiting localized response to painful stimuli.
Answer: A
Rationale: A GCS score of 8 or less is generally used as the threshold to define a coma and
indicates a severe brain injury. At a score of 7, the client likely lacks the ability to protect
their own airway, necessitating intubation. This scale assesses eye-opening, verbal
response, and motor response to determine neurological status.
7. A nurse is caring for a client with increased intracranial pressure (ICP) following a head
injury. Which position is most appropriate for this client?
A. Supine with the head of the bed flat
B. Side-lying with the knees flexed to the chest
C. Trendelenburg position to improve cerebral perfusion
D. Head of the bed elevated 30 to 45 degrees with head midline
Answer: D
Rationale: Elevating the head of the bed facilitates venous drainage from the brain, which
helps reduce intracranial pressure. Maintaining the head in a midline position prevents
obstruction of the jugular veins. Extreme hip flexion or a flat position can impede drainage
and should be avoided in clients with elevated ICP.
8. Which clinical manifestation should the nurse expect to find in a client diagnosed with
Diabetes Insipidus (DI)?
A. High urine specific gravity and fluid volume excess
B. Excessive thirst and high urine output with low specific gravity
C. Low serum sodium and peripheral edema
D. Weight gain and concentrated dark urine
Answer: B
Rationale: Diabetes Insipidus is characterized by a deficiency in antidiuretic hormone
(ADH), leading to the excretion of large amounts of dilute urine. This results in polyuria,
polydipsia, and a low urine specific gravity (usually below 1.005). The nurse must monitor
for dehydration and hypernatremia as the body loses free water.
9. A client with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) is being treated.
Which of the following provider orders should the nurse clarify?
A. Fluid restriction of 800 mL per day
B. Administration of 0.45% Sodium Chloride IV at 125 mL/hr
