lOMoARcPSD| 69811638
MDC4 EXAM 1 QUESTIONS AND
ANSWERS WITH COMPLETE
SOLUTIONS ALREADY PASSED!!!
Question 1 A client involved in a motor vehicle collision (MVC) presents with
signs and symptoms of elevated intracranial pressure (ICP). What is the single
most significant and earliest indicator of increasing ICP?
A. Pupil changes B. Ipsilateral paralysis C. Vomiting D. Decrease in level of
consciousness (LOC)
✔️✔️ D. Decrease in LOC
(Explanation: A change or decline in the level of consciousness is the earliest,
most sensitive, and most reliable indicator of worsening intracranial pressure and
compromised cerebral perfusion.)
Question 2 A client who recently suffered a stroke presents with left-sided
weakness. The nurse assesses the client for dysphagia, particularly when
consuming thin liquids. Which intervention is most effective in aiding the client to
swallow safely and prevent aspiration?
A. Avoid all liquid intake entirely B. Instruct the client to tuck their chin toward
the chest when swallowing C. Offer small sips of water with every bite of solid
food D. Direct the client to turn their head toward the affected left side while
swallowing
✔️✔️ B. Instructing to tuck the chin when swallowing
(Explanation: The chin-tuck maneuver widens the vallecula, closes the vocal
cords, and narrows the airway entrance, significantly reducing the risk of thin
liquids entering the trachea during swallowing.)
Question 3 A nurse evaluates a 27-year-old female client who reports a multi-
month history of progressive muscle weakness and loss of motor coordination.
Which central nervous system disorder is most consistent with this presentation?
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A. Systemic Lupus Erythematosus B. Multiple Sclerosis C. Guillain-Barré
Syndrome D. Myasthenia Gravis
✔️✔️ B. Multiple Sclerosis
(Explanation: Multiple Sclerosis is an autoimmune demyelinating disease of the
central nervous system that typically onset in young adults (predominantly females
aged 20–40) and characteristically manifests with progressive motor weakness,
spasticity, and impaired coordination.)
Question 4 During an assessment of a client recovering from a recent tonic-clonic
seizure, which clinical finding should the nurse recognize as characteristic of the
postictal phase?
A. The patient's motor function is gradually returning to baseline B. The patient
describes experiencing a bright visual aura C. The patient demonstrates brief,
sudden jerking movements of the extremities D. The patient's oxygen saturation
drops significantly to 80%
✔️✔️ A. Patients motor functions is returning to baseline
(Explanation: The postictal phase is the recovery period following a seizure,
marked by a gradual restoration of neurological and motor function back to
baseline as post-seizure confusion and fatigue resolve.)
A. Place the neck in a neutral position to promote venous drainage -
ANSWER✔️✔️The client has a head injury and is presenting with signs and
symptoms of increased ICP. Which nursing intervention would be helpful in
reducing this pressure?
A. Place the neck in a neutral position to promote venous drainage
B. Suction hourly to stimulate the couch reflex
C. Add extra blankets to keep the client warm
D. Turn the client frequently to prevent skin impairment
, lOMoARcPSD| 69811638
C. Lumbar Puncture -ANSWER✔️✔️A patient injured in an MVA is being
evaluated at the emergency department for a possible head injury. Which test
should NOT be done if there is indication of increased ICP?
A. CT Scan
B. MRI Scan
C. Lumbar Puncture
D. Electroencephalogram
B. I just got over the flu a couple of weeks ago and now this -ANSWER✔️✔️The
nurse is obtaining a health history for a 45yr old woman with Guillain-Barre
Syndrome (GBS). Which statement by the client does the nurse correlate with the
clients diagnosis?
A. I have history of a cardiac dysrhythmia
B. I just got over the flu a couple of weeks ago and now this
C. My neighbor also has Guillain-Barre syndrome
D. I am an artist and work with oil paints
C. Identify the time of onset of the stroke -ANSWER✔️✔️A client arrives in the
emergency department with an ischemic stroke. Because the healthcare team is
considering administering tissue plasminogen activator (t-PA), what should the
nurse perform first?
A. Ask what medications the client is taking
B. Complete the history and health assessement
MDC4 EXAM 1 QUESTIONS AND
ANSWERS WITH COMPLETE
SOLUTIONS ALREADY PASSED!!!
Question 1 A client involved in a motor vehicle collision (MVC) presents with
signs and symptoms of elevated intracranial pressure (ICP). What is the single
most significant and earliest indicator of increasing ICP?
A. Pupil changes B. Ipsilateral paralysis C. Vomiting D. Decrease in level of
consciousness (LOC)
✔️✔️ D. Decrease in LOC
(Explanation: A change or decline in the level of consciousness is the earliest,
most sensitive, and most reliable indicator of worsening intracranial pressure and
compromised cerebral perfusion.)
Question 2 A client who recently suffered a stroke presents with left-sided
weakness. The nurse assesses the client for dysphagia, particularly when
consuming thin liquids. Which intervention is most effective in aiding the client to
swallow safely and prevent aspiration?
A. Avoid all liquid intake entirely B. Instruct the client to tuck their chin toward
the chest when swallowing C. Offer small sips of water with every bite of solid
food D. Direct the client to turn their head toward the affected left side while
swallowing
✔️✔️ B. Instructing to tuck the chin when swallowing
(Explanation: The chin-tuck maneuver widens the vallecula, closes the vocal
cords, and narrows the airway entrance, significantly reducing the risk of thin
liquids entering the trachea during swallowing.)
Question 3 A nurse evaluates a 27-year-old female client who reports a multi-
month history of progressive muscle weakness and loss of motor coordination.
Which central nervous system disorder is most consistent with this presentation?
, lOMoARcPSD| 69811638
A. Systemic Lupus Erythematosus B. Multiple Sclerosis C. Guillain-Barré
Syndrome D. Myasthenia Gravis
✔️✔️ B. Multiple Sclerosis
(Explanation: Multiple Sclerosis is an autoimmune demyelinating disease of the
central nervous system that typically onset in young adults (predominantly females
aged 20–40) and characteristically manifests with progressive motor weakness,
spasticity, and impaired coordination.)
Question 4 During an assessment of a client recovering from a recent tonic-clonic
seizure, which clinical finding should the nurse recognize as characteristic of the
postictal phase?
A. The patient's motor function is gradually returning to baseline B. The patient
describes experiencing a bright visual aura C. The patient demonstrates brief,
sudden jerking movements of the extremities D. The patient's oxygen saturation
drops significantly to 80%
✔️✔️ A. Patients motor functions is returning to baseline
(Explanation: The postictal phase is the recovery period following a seizure,
marked by a gradual restoration of neurological and motor function back to
baseline as post-seizure confusion and fatigue resolve.)
A. Place the neck in a neutral position to promote venous drainage -
ANSWER✔️✔️The client has a head injury and is presenting with signs and
symptoms of increased ICP. Which nursing intervention would be helpful in
reducing this pressure?
A. Place the neck in a neutral position to promote venous drainage
B. Suction hourly to stimulate the couch reflex
C. Add extra blankets to keep the client warm
D. Turn the client frequently to prevent skin impairment
, lOMoARcPSD| 69811638
C. Lumbar Puncture -ANSWER✔️✔️A patient injured in an MVA is being
evaluated at the emergency department for a possible head injury. Which test
should NOT be done if there is indication of increased ICP?
A. CT Scan
B. MRI Scan
C. Lumbar Puncture
D. Electroencephalogram
B. I just got over the flu a couple of weeks ago and now this -ANSWER✔️✔️The
nurse is obtaining a health history for a 45yr old woman with Guillain-Barre
Syndrome (GBS). Which statement by the client does the nurse correlate with the
clients diagnosis?
A. I have history of a cardiac dysrhythmia
B. I just got over the flu a couple of weeks ago and now this
C. My neighbor also has Guillain-Barre syndrome
D. I am an artist and work with oil paints
C. Identify the time of onset of the stroke -ANSWER✔️✔️A client arrives in the
emergency department with an ischemic stroke. Because the healthcare team is
considering administering tissue plasminogen activator (t-PA), what should the
nurse perform first?
A. Ask what medications the client is taking
B. Complete the history and health assessement
