NSG 4100 (AH111) EXAM 4 NEWEST 2025 ACTUAL
EXAM COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
A nurse is caring for a client diagnosed to have a head injury. Which of the
following situations needs intervention by the nurse? - ans -The client's spouse
turns on the TV one hours in the afternoon and 3 hours in the evening.
(You need low stimulation)
In a client with head injury ICP, . External stimuli should be
to oxygen consumption and prevent seizures. - ans -1.
increases 2. Reduced 3. Decrease
The critical care nurse is caring for a client with a head injury secondary to a MVA.
In the am the patient is responsive to painful stimuli and assumed decorticate
The patient with fibromyalgiai suffering from pain at 12 of the 18 identification
site sites, including the neck upper back and the knees. The patient also reports
nonfreshing sleep, depression, and being anxious when dealing with multiple
tasks. The nurse should teach the patient about what treatments? (SATA)
- ans --Relaxation strategy (biofeedback)
-Serotonin reputake inhihibitor (e.g setraline)
-Establish a regular sleep patern
-Instruct patient on performing regular LOW IMPACT exercise such as walking,
swimming, biking and water exercise.
What medicaitons are approved for fibromyalgia pain? - ans -Antidepressants
(preglabalin & duloxetine) as these meds work to release serotonin and nor-
epinephrine in the brain
The nurse is caring for a client with a head injury and would recognize which
assessment findings as early sings of increase ICP? SATA - ans --Kussmaul
breathing
-Weakness in one extremity
,posturing. Two hours later which data would warrent immediate intervention by
the nurse? - ans -The client extends the upper and lower extremities in response
to painful stimuli
Extension of the upper and lower extremities is assuming a posture,
which indicated the client's intracranial pressure is - ans -1.
Decerebrate 2. Increasing
The nurse is caring for clients in the emergency department. Which client should
the nurse assess first? - ans -The client with an epidural hematoma
An epidural hemtoma results from bleeding between the dura and inner surface
of the skull, and is an active bleed. This is a MEDICAL EMERGENCY.
- ans -Arterial
A female patient has experienced an episode of myasthenic crisis. The nurse
would assess whether the patient is precipitating factors such as? - ans -Omitting
doses of medication
Myasthenic crisis often is caused by -medication and responds to
the administration of cholinergic medications such as neostigmine and
- ans -1. Over Under 2. Pyridostigmine
What is the treatment for Guillian Barre - ans -Plasmapherisis
What is the treatment for Bacterial Meningitis? - ans -Broad Spectrum Antibiotics
What is the treatment for Spinal Cord injury? - ans -Methylprednisone
What is the treatment for Increased ICP? - ans -Mannitol
What is the treatment for Neurogenic Shock? - ans -Atropine Sulfate
What is the treatment for Autonomic Dysreflexia? - ans -Hydralizine IV
, - ans -Beefy red tissue indicated tissue death
A patient is admitted to the burn unit with burns to the head, face and hands.
Initially, wheezes are heard but an hour later, the lung sounds are decreased and
no wheezes are audible. What is the best action for the nurse to take? - ans -
Notify the health care provider and prepare for endotracheal intubation
While the patient's full thickness burn wounds to the face are exposed, what is
the best nursing action to prevent cross contamination? - ans -Wear gowns, caps,
masks, and gloves during all care of the patient
kublar-ross stages of grief - ans -1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Complications of severe head injuries? - ans -Complications:
-Brain stem injury
-Neurogenic shock
-Increased ICP
CM of Brain Stem Injury? - ans -Edema, Hemorrhage, dolls eyes, Increased ICP
Your patient has undergone a brain tumor removal. What are post op
considerations you would implement as the nurse? - ans --Check Vital signs and
for S/S of increased ICP
-Assess for CSF drainage
-DANGER if 50-100 mls shift contact MD immediatley
"BP systolic not over 130 for r/f Cushings Triad MAP, reduce edema" (idk)
CM of increased ICP? - ans -The earliest sign of Increased ICP is a change in LOC=
Agitiation, slowing of speech and a delay in response to verbal suggestions
EXAM COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
A nurse is caring for a client diagnosed to have a head injury. Which of the
following situations needs intervention by the nurse? - ans -The client's spouse
turns on the TV one hours in the afternoon and 3 hours in the evening.
(You need low stimulation)
In a client with head injury ICP, . External stimuli should be
to oxygen consumption and prevent seizures. - ans -1.
increases 2. Reduced 3. Decrease
The critical care nurse is caring for a client with a head injury secondary to a MVA.
In the am the patient is responsive to painful stimuli and assumed decorticate
The patient with fibromyalgiai suffering from pain at 12 of the 18 identification
site sites, including the neck upper back and the knees. The patient also reports
nonfreshing sleep, depression, and being anxious when dealing with multiple
tasks. The nurse should teach the patient about what treatments? (SATA)
- ans --Relaxation strategy (biofeedback)
-Serotonin reputake inhihibitor (e.g setraline)
-Establish a regular sleep patern
-Instruct patient on performing regular LOW IMPACT exercise such as walking,
swimming, biking and water exercise.
What medicaitons are approved for fibromyalgia pain? - ans -Antidepressants
(preglabalin & duloxetine) as these meds work to release serotonin and nor-
epinephrine in the brain
The nurse is caring for a client with a head injury and would recognize which
assessment findings as early sings of increase ICP? SATA - ans --Kussmaul
breathing
-Weakness in one extremity
,posturing. Two hours later which data would warrent immediate intervention by
the nurse? - ans -The client extends the upper and lower extremities in response
to painful stimuli
Extension of the upper and lower extremities is assuming a posture,
which indicated the client's intracranial pressure is - ans -1.
Decerebrate 2. Increasing
The nurse is caring for clients in the emergency department. Which client should
the nurse assess first? - ans -The client with an epidural hematoma
An epidural hemtoma results from bleeding between the dura and inner surface
of the skull, and is an active bleed. This is a MEDICAL EMERGENCY.
- ans -Arterial
A female patient has experienced an episode of myasthenic crisis. The nurse
would assess whether the patient is precipitating factors such as? - ans -Omitting
doses of medication
Myasthenic crisis often is caused by -medication and responds to
the administration of cholinergic medications such as neostigmine and
- ans -1. Over Under 2. Pyridostigmine
What is the treatment for Guillian Barre - ans -Plasmapherisis
What is the treatment for Bacterial Meningitis? - ans -Broad Spectrum Antibiotics
What is the treatment for Spinal Cord injury? - ans -Methylprednisone
What is the treatment for Increased ICP? - ans -Mannitol
What is the treatment for Neurogenic Shock? - ans -Atropine Sulfate
What is the treatment for Autonomic Dysreflexia? - ans -Hydralizine IV
, - ans -Beefy red tissue indicated tissue death
A patient is admitted to the burn unit with burns to the head, face and hands.
Initially, wheezes are heard but an hour later, the lung sounds are decreased and
no wheezes are audible. What is the best action for the nurse to take? - ans -
Notify the health care provider and prepare for endotracheal intubation
While the patient's full thickness burn wounds to the face are exposed, what is
the best nursing action to prevent cross contamination? - ans -Wear gowns, caps,
masks, and gloves during all care of the patient
kublar-ross stages of grief - ans -1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Complications of severe head injuries? - ans -Complications:
-Brain stem injury
-Neurogenic shock
-Increased ICP
CM of Brain Stem Injury? - ans -Edema, Hemorrhage, dolls eyes, Increased ICP
Your patient has undergone a brain tumor removal. What are post op
considerations you would implement as the nurse? - ans --Check Vital signs and
for S/S of increased ICP
-Assess for CSF drainage
-DANGER if 50-100 mls shift contact MD immediatley
"BP systolic not over 130 for r/f Cushings Triad MAP, reduce edema" (idk)
CM of increased ICP? - ans -The earliest sign of Increased ICP is a change in LOC=
Agitiation, slowing of speech and a delay in response to verbal suggestions
