1
NSG
NSG 4100 (AHIII) EXAM 4 TESTBANK
QUESTIONS WITH CORRECT VERIFIED SOLUTIONS
100% GUARANTEED PASS
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is
contraindicated in this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - ANS ✓B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care
plan should specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
c. projectile vomiting
d. loss of corneal reflex - ANS ✓A
The neurologic ICU nurse is admitting a pt following a craniotomy using the supratentorial
approach. How should the nurse best position the pt?
a. position the pt supine
b. maintain HOB elevated at 30-45 degrees
c. position pt in prone position
d. maintain bed in Trendelenberg position - ANS ✓B
A pt has developed diabetes insipidness after having increased ICP following head trauma.
What nursing assessment best addresses this complication?
a. vigilant monitoring of fluid balance
b. continuous BP monitoring
c. serial arterial blood gases (ABGs)
d. monitoring of the pt's airway for patency - ANS ✓A
What would the nurse suspect when hourly assessment of UO on a pt postcrainiotomy
exhibits a urine output from a catheter of 1,500mL for 2 consecutive hours?
a. ruching syndrom
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - ANS ✓D
NSG 4100
, 2
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During the exam of an unconscious pt, the nurse observes that the pt's pupils are fixed and
dilated. What is the most plausible clinical significant of the nurses finding?
a. it suggests onset of metabolic problems
b. it indicates paralysis on the right side of the body
c. it indicates paralysis of cranial nerve X
d. it indicates an injury at the midbrain level - ANS ✓D
Following a traumatic brain injury, a pt has been in a coma for several days. Which of the
following statements is true of this pt's current LOC?
a. the pt occasionally makes incomprehensible sounds
b. the pt's current LOC will likely become a permanent state
c. the pt may occasionally make non purposeful movements
d. the pt is incapable of spontaneous respirations - ANS ✓C
The nurse is caring for a pt w permanent neurologic impairments resulting from a traumatic
head injury. When working w this pt and family, what mutual goal should be prioritized?
a. achieve as high a level of function as possible
b. enhance the quantity of the pt's life
c. teach the family proper care of the pt
d. provide community assistance - ANS ✓A
The nurse is caring for a pt whose recent health hx includes an altered LOC. What should be
the nurses first action when assessing this pt?
a. assessing the pt's verbal response
b. assessing the pt's ability to follow complex commands
c. assessing the pt's judgment
d. assessing the pt's response to pain - ANS ✓A
The nurse for a pt in a persistent vegetative state is regularly assessing for potential
complications. Complications of neurologic dysfunction for which the nurse should assess
include which of the following? Select all that apply:
a. contractures
b. hemorrhage
c. pressure ulcers
d. venous thromboembolism
e. pneumonia - ANS ✓A, C, D, E
The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to be ordered
to reduce the edema surrounding the tumor?
a. solumedrol
b. dextromethorphan
c. dexamethasone
d. furosemide - ANS ✓C
NSG 4100
, 3
NSG
The nurse is caring for a pt who sustained a moderate head injury following a bicycle
accident. The nurses most recent assessment reveals that the pt's respiratory effort has
increased. What is the nurses most appropriate response?
a. inform the care team and assess for further signs of possible increased ICP
b. administer bronchodilators and monitor the pt's LOC
c. increase the pt's bed height and reassess in 30 mins
d. administer a bolus of normal line as ordered - ANS ✓A
A pt has a poor prognosis after being involved in a motor vehicle accident resulting in a head
injury. As the pt's ICP increases and condition worsens, the nurse knows to assess for
indications of approaching death. These indications include which of the following?
a. hemiplegia
b. dry mucous membranes
c. signs of internal bleeding
d. loss of brain stem reflexes - ANS ✓D
When caring for a pt w increased ICP the nurse knows the importance of monitoring for
possible secondary complications, including syndrome of inappropriate antidiuretic hormone
(SIADH). What nursing interventions would the nurse most likely initiate if the pt developed
SIADH?
a. fluid restriction
b. transfusion of platelets
c. transfusion of fresh frozen plasma (FFP)
d. electrolyte restriction - ANS ✓A
A pt is recovering from an intracranial surgery performed approximately 24 hrs ago and is
complaining of a headache that the pt rates at 8 on a 10-point pain scale. What nursing action
is most appropriate?
a. administer morphine sulfate as ordered
b. reposition the pt in a prone position
c. apply a hot pack to the pt's scalp
d. implement distraction techniques - ANS ✓A
A pt is postoperative day 1 following intracranial surgery. The nurses assessment reveals that
the LOC is slightly decreased w the day of surgery. What is the nurses best response to this
assessment finding?
a. recognize that this may represent the peak of post-surgical cerebral edema
b. alert the surgeon to the possibility of an intracranial hemorrhage
c. understand that the surgery may have been unsuccessful
d. recognize the need to refer the pt to the palliative care team - ANS ✓A
A pt w a cerebral aneurysm exhibits s/s of an increase in ICP. What nursing intervention
would be the most appropriate for this pt?
a. ROM exercises to prevent contractors
b. encouraging independence w ADLs to promote recovery
c. early initiation of physical therapy
NSG 4100
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d. absolute bed rest in a quiet, non stimulating environment - ANS ✓D
A pt has been admitted to the ICU after being recently diagnosed w an aneurysm and the pt's
admission orders include specific aneurysm precautions. What nursing action will the nurse
incorporate into the pt's plan of care?
a. elevate the HOB to 45 degrees
b. maintain the pt on complete bed rest
c. administer enemas when the pt is constipated
d. avoid use of thigh-high elastic compression stockings - ANS ✓B
A pt diagnosed w a cerebral aneurysm reports a severe HA to the nurse. What action is a
priority for the nurse?
a. sit w the pt for a few minutes
b. administer an analgesic
c. inform the nurse-manager
d. call the physician immediately - ANS ✓D
When caring for a pt who has had a stroke, a priority is reduction of ICP. What pt position is
most consistent w this goal?
a. head turned slightly to the R side
b. elevation of HOB
c. position changes q15min while awake
d. extension of neck - ANS ✓B
After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium
level of less than 126 mEq/L. What is the nurse's most appropriate action
a. administer a bolus of normal saline as ordered
b. prepare pt for thrombolytic therapy as ordered
c. facilitate testing for hypothalamic dysfunction
d. prepare to administer 3% NaCl by IV as ordered - ANS ✓D
Following diagnostic testing, a pt has been admitted to the ICU and placed on cerebral
aneurysm precautions. What nursing action should be included in pt's plan of care?
a. supervise the pt's activities of daily living closely
b. initiate early ambulation to prevent complications of immobility
c. provide a high-calorie, low-protein diet
d. perform all of the pt's hygiene and feeding - ANS ✓A
A pt is brought to the trauma center by ambulance after sustaining a high cervical spinal cord
injury 1 hour ago. Endotracheal intubation has been deemed necessary and the nurse is
preparing to assist. What nursing dx should the nurse associate w this procedure?
a. risk for impaired skin integrity
b. risk for injury
c. risk for autonomic dysreflexia
d. risk for suffocation - ANS ✓B
NSG 4100
NSG
NSG 4100 (AHIII) EXAM 4 TESTBANK
QUESTIONS WITH CORRECT VERIFIED SOLUTIONS
100% GUARANTEED PASS
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is
contraindicated in this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - ANS ✓B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care
plan should specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
c. projectile vomiting
d. loss of corneal reflex - ANS ✓A
The neurologic ICU nurse is admitting a pt following a craniotomy using the supratentorial
approach. How should the nurse best position the pt?
a. position the pt supine
b. maintain HOB elevated at 30-45 degrees
c. position pt in prone position
d. maintain bed in Trendelenberg position - ANS ✓B
A pt has developed diabetes insipidness after having increased ICP following head trauma.
What nursing assessment best addresses this complication?
a. vigilant monitoring of fluid balance
b. continuous BP monitoring
c. serial arterial blood gases (ABGs)
d. monitoring of the pt's airway for patency - ANS ✓A
What would the nurse suspect when hourly assessment of UO on a pt postcrainiotomy
exhibits a urine output from a catheter of 1,500mL for 2 consecutive hours?
a. ruching syndrom
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - ANS ✓D
NSG 4100
, 2
NSG
During the exam of an unconscious pt, the nurse observes that the pt's pupils are fixed and
dilated. What is the most plausible clinical significant of the nurses finding?
a. it suggests onset of metabolic problems
b. it indicates paralysis on the right side of the body
c. it indicates paralysis of cranial nerve X
d. it indicates an injury at the midbrain level - ANS ✓D
Following a traumatic brain injury, a pt has been in a coma for several days. Which of the
following statements is true of this pt's current LOC?
a. the pt occasionally makes incomprehensible sounds
b. the pt's current LOC will likely become a permanent state
c. the pt may occasionally make non purposeful movements
d. the pt is incapable of spontaneous respirations - ANS ✓C
The nurse is caring for a pt w permanent neurologic impairments resulting from a traumatic
head injury. When working w this pt and family, what mutual goal should be prioritized?
a. achieve as high a level of function as possible
b. enhance the quantity of the pt's life
c. teach the family proper care of the pt
d. provide community assistance - ANS ✓A
The nurse is caring for a pt whose recent health hx includes an altered LOC. What should be
the nurses first action when assessing this pt?
a. assessing the pt's verbal response
b. assessing the pt's ability to follow complex commands
c. assessing the pt's judgment
d. assessing the pt's response to pain - ANS ✓A
The nurse for a pt in a persistent vegetative state is regularly assessing for potential
complications. Complications of neurologic dysfunction for which the nurse should assess
include which of the following? Select all that apply:
a. contractures
b. hemorrhage
c. pressure ulcers
d. venous thromboembolism
e. pneumonia - ANS ✓A, C, D, E
The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to be ordered
to reduce the edema surrounding the tumor?
a. solumedrol
b. dextromethorphan
c. dexamethasone
d. furosemide - ANS ✓C
NSG 4100
, 3
NSG
The nurse is caring for a pt who sustained a moderate head injury following a bicycle
accident. The nurses most recent assessment reveals that the pt's respiratory effort has
increased. What is the nurses most appropriate response?
a. inform the care team and assess for further signs of possible increased ICP
b. administer bronchodilators and monitor the pt's LOC
c. increase the pt's bed height and reassess in 30 mins
d. administer a bolus of normal line as ordered - ANS ✓A
A pt has a poor prognosis after being involved in a motor vehicle accident resulting in a head
injury. As the pt's ICP increases and condition worsens, the nurse knows to assess for
indications of approaching death. These indications include which of the following?
a. hemiplegia
b. dry mucous membranes
c. signs of internal bleeding
d. loss of brain stem reflexes - ANS ✓D
When caring for a pt w increased ICP the nurse knows the importance of monitoring for
possible secondary complications, including syndrome of inappropriate antidiuretic hormone
(SIADH). What nursing interventions would the nurse most likely initiate if the pt developed
SIADH?
a. fluid restriction
b. transfusion of platelets
c. transfusion of fresh frozen plasma (FFP)
d. electrolyte restriction - ANS ✓A
A pt is recovering from an intracranial surgery performed approximately 24 hrs ago and is
complaining of a headache that the pt rates at 8 on a 10-point pain scale. What nursing action
is most appropriate?
a. administer morphine sulfate as ordered
b. reposition the pt in a prone position
c. apply a hot pack to the pt's scalp
d. implement distraction techniques - ANS ✓A
A pt is postoperative day 1 following intracranial surgery. The nurses assessment reveals that
the LOC is slightly decreased w the day of surgery. What is the nurses best response to this
assessment finding?
a. recognize that this may represent the peak of post-surgical cerebral edema
b. alert the surgeon to the possibility of an intracranial hemorrhage
c. understand that the surgery may have been unsuccessful
d. recognize the need to refer the pt to the palliative care team - ANS ✓A
A pt w a cerebral aneurysm exhibits s/s of an increase in ICP. What nursing intervention
would be the most appropriate for this pt?
a. ROM exercises to prevent contractors
b. encouraging independence w ADLs to promote recovery
c. early initiation of physical therapy
NSG 4100
, 4
NSG
d. absolute bed rest in a quiet, non stimulating environment - ANS ✓D
A pt has been admitted to the ICU after being recently diagnosed w an aneurysm and the pt's
admission orders include specific aneurysm precautions. What nursing action will the nurse
incorporate into the pt's plan of care?
a. elevate the HOB to 45 degrees
b. maintain the pt on complete bed rest
c. administer enemas when the pt is constipated
d. avoid use of thigh-high elastic compression stockings - ANS ✓B
A pt diagnosed w a cerebral aneurysm reports a severe HA to the nurse. What action is a
priority for the nurse?
a. sit w the pt for a few minutes
b. administer an analgesic
c. inform the nurse-manager
d. call the physician immediately - ANS ✓D
When caring for a pt who has had a stroke, a priority is reduction of ICP. What pt position is
most consistent w this goal?
a. head turned slightly to the R side
b. elevation of HOB
c. position changes q15min while awake
d. extension of neck - ANS ✓B
After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium
level of less than 126 mEq/L. What is the nurse's most appropriate action
a. administer a bolus of normal saline as ordered
b. prepare pt for thrombolytic therapy as ordered
c. facilitate testing for hypothalamic dysfunction
d. prepare to administer 3% NaCl by IV as ordered - ANS ✓D
Following diagnostic testing, a pt has been admitted to the ICU and placed on cerebral
aneurysm precautions. What nursing action should be included in pt's plan of care?
a. supervise the pt's activities of daily living closely
b. initiate early ambulation to prevent complications of immobility
c. provide a high-calorie, low-protein diet
d. perform all of the pt's hygiene and feeding - ANS ✓A
A pt is brought to the trauma center by ambulance after sustaining a high cervical spinal cord
injury 1 hour ago. Endotracheal intubation has been deemed necessary and the nurse is
preparing to assist. What nursing dx should the nurse associate w this procedure?
a. risk for impaired skin integrity
b. risk for injury
c. risk for autonomic dysreflexia
d. risk for suffocation - ANS ✓B
NSG 4100
