NUR 2755 – Multidimensional Care IV (MDC
4) Exam 1 Questions with Answers|
Rasmussen University| Updated| Pass
Guaranteed
1.
A client arrives in the emergency department after a motor-vehicle collision. Which assessment
should the nurse perform first?
A. Assess pain level
B. Assess airway patency
C. Obtain a complete health history
D. Assess bowel sounds
Correct Answer: B
Rationale: In trauma care, the nurse first addresses immediate threats to life. Airway
assessment is an ABC priority, particularly because cervical spine injury may also be present.
2.
A client with a head injury suddenly becomes difficult to arouse. What is the nurse's priority?
A. Offer oral fluids
B. Assess airway, breathing, and neurologic status
C. Encourage ambulation
D. Provide a meal
Correct Answer: B
Rationale: A sudden decrease in level of consciousness may indicate worsening intracranial
pathology. Immediate assessment of ABCs and neurologic status is essential.
3.
Which finding is most concerning for increased intracranial pressure (ICP)?
,A. Mild headache
B. Decreasing level of consciousness
C. Increased appetite
D. Warm hands
Correct Answer: B
Rationale: A declining level of consciousness is an important sign of worsening neurologic
function and possible increased ICP.
4.
A client with a traumatic brain injury develops unequal pupils. What should the nurse do?
A. Document as an expected finding
B. Notify the healthcare provider immediately
C. Encourage sleep
D. Give oral fluids
Correct Answer: B
Rationale: New unequal pupils can indicate neurologic deterioration, including compression of
cranial structures, and require immediate evaluation.
5.
Which position is generally appropriate for a client with increased ICP when not
contraindicated?
A. Flat with the neck flexed
B. Head elevated with the neck in neutral alignment
C. Trendelenburg
D. Prone with the head turned sharply
Correct Answer: B
Rationale: Elevating the head and maintaining neutral neck alignment can promote venous
drainage from the brain and help reduce ICP.
6.
,Which intervention should the nurse avoid in a client with increased ICP?
A. Maintaining a neutral neck position
B. Preventing unnecessary stimulation
C. Frequent unnecessary suctioning
D. Monitoring neurologic status
Correct Answer: C
Rationale: Suctioning can transiently increase ICP. It should be performed only when clinically
necessary and with appropriate precautions.
7.
A client with a head injury develops hypertension, bradycardia, and irregular respirations.
Which condition should the nurse suspect?
A. Cushing response
B. Hypoglycemia
C. Spinal shock
D. Dehydration
Correct Answer: A
Rationale: Hypertension with widening pulse pressure, bradycardia, and abnormal respirations
can indicate a Cushing response associated with increased ICP and possible brain herniation.
8.
Which assessment is most important when monitoring a client with a neurologic disorder?
A. Level of consciousness
B. Hair color
C. Appetite alone
D. Nail length
Correct Answer: A
Rationale: Changes in level of consciousness can be an early indicator of neurologic
deterioration.
, 9.
A client after head trauma begins vomiting repeatedly and develops worsening headache. What
should the nurse suspect?
A. Possible increased ICP
B. Improved neurologic status
C. Normal recovery
D. Mild dehydration only
Correct Answer: A
Rationale: Worsening headache and repeated vomiting can occur with increased ICP and
require prompt neurologic reassessment.
10.
Which finding is most concerning after a head injury?
A. Mild scalp tenderness
B. Increasing confusion
C. Hunger
D. Mild fatigue
Correct Answer: B
Rationale: Increasing confusion represents a change in neurologic status and may indicate
intracranial bleeding or increasing ICP.
11.
A client with suspected spinal cord injury arrives after a diving accident. What is the priority?
A. Encourage neck movement
B. Maintain spinal alignment and immobilization
C. Place the client in a chair
D. Encourage walking
Correct Answer: B
Rationale: Movement of an unstable spinal column can worsen neurologic injury. Spinal
alignment and immobilization are priorities until injury is excluded.
4) Exam 1 Questions with Answers|
Rasmussen University| Updated| Pass
Guaranteed
1.
A client arrives in the emergency department after a motor-vehicle collision. Which assessment
should the nurse perform first?
A. Assess pain level
B. Assess airway patency
C. Obtain a complete health history
D. Assess bowel sounds
Correct Answer: B
Rationale: In trauma care, the nurse first addresses immediate threats to life. Airway
assessment is an ABC priority, particularly because cervical spine injury may also be present.
2.
A client with a head injury suddenly becomes difficult to arouse. What is the nurse's priority?
A. Offer oral fluids
B. Assess airway, breathing, and neurologic status
C. Encourage ambulation
D. Provide a meal
Correct Answer: B
Rationale: A sudden decrease in level of consciousness may indicate worsening intracranial
pathology. Immediate assessment of ABCs and neurologic status is essential.
3.
Which finding is most concerning for increased intracranial pressure (ICP)?
,A. Mild headache
B. Decreasing level of consciousness
C. Increased appetite
D. Warm hands
Correct Answer: B
Rationale: A declining level of consciousness is an important sign of worsening neurologic
function and possible increased ICP.
4.
A client with a traumatic brain injury develops unequal pupils. What should the nurse do?
A. Document as an expected finding
B. Notify the healthcare provider immediately
C. Encourage sleep
D. Give oral fluids
Correct Answer: B
Rationale: New unequal pupils can indicate neurologic deterioration, including compression of
cranial structures, and require immediate evaluation.
5.
Which position is generally appropriate for a client with increased ICP when not
contraindicated?
A. Flat with the neck flexed
B. Head elevated with the neck in neutral alignment
C. Trendelenburg
D. Prone with the head turned sharply
Correct Answer: B
Rationale: Elevating the head and maintaining neutral neck alignment can promote venous
drainage from the brain and help reduce ICP.
6.
,Which intervention should the nurse avoid in a client with increased ICP?
A. Maintaining a neutral neck position
B. Preventing unnecessary stimulation
C. Frequent unnecessary suctioning
D. Monitoring neurologic status
Correct Answer: C
Rationale: Suctioning can transiently increase ICP. It should be performed only when clinically
necessary and with appropriate precautions.
7.
A client with a head injury develops hypertension, bradycardia, and irregular respirations.
Which condition should the nurse suspect?
A. Cushing response
B. Hypoglycemia
C. Spinal shock
D. Dehydration
Correct Answer: A
Rationale: Hypertension with widening pulse pressure, bradycardia, and abnormal respirations
can indicate a Cushing response associated with increased ICP and possible brain herniation.
8.
Which assessment is most important when monitoring a client with a neurologic disorder?
A. Level of consciousness
B. Hair color
C. Appetite alone
D. Nail length
Correct Answer: A
Rationale: Changes in level of consciousness can be an early indicator of neurologic
deterioration.
, 9.
A client after head trauma begins vomiting repeatedly and develops worsening headache. What
should the nurse suspect?
A. Possible increased ICP
B. Improved neurologic status
C. Normal recovery
D. Mild dehydration only
Correct Answer: A
Rationale: Worsening headache and repeated vomiting can occur with increased ICP and
require prompt neurologic reassessment.
10.
Which finding is most concerning after a head injury?
A. Mild scalp tenderness
B. Increasing confusion
C. Hunger
D. Mild fatigue
Correct Answer: B
Rationale: Increasing confusion represents a change in neurologic status and may indicate
intracranial bleeding or increasing ICP.
11.
A client with suspected spinal cord injury arrives after a diving accident. What is the priority?
A. Encourage neck movement
B. Maintain spinal alignment and immobilization
C. Place the client in a chair
D. Encourage walking
Correct Answer: B
Rationale: Movement of an unstable spinal column can worsen neurologic injury. Spinal
alignment and immobilization are priorities until injury is excluded.
