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MEDICAL SURGICAL NURSING FINAL NEWEST
ACTUAL EXAM COMPLETE 205 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
Management of Patients with Neurologic Dysfunction - ANSWER
✔✔- Management of Patients with Neurologic Dysfunction
A patient is being admitted to the neurologic ICU following an
acute head injury that has resulted in cerebral edema. When
planning this patients care, the nurse would expect to administer
what priority medication?
A) Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix)
C) Mannitol (Osmitrol)
D) Spirolactone (Aldactone) - ANSWER ✔✔- C) Mannitol
(Osmitrol)
The nurse is providing care for a patient who is unconscious.
What nursing intervention takes highest priority?
A) Maintaining accurate records of intake and output
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control - ANSWER ✔✔- B)
Maintaining a patent airway
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The nurse is caring for a patient in the ICU who has a brain stem
herniation and who is exhibiting an altered level of consciousness.
Monitoring reveals that the patients mean arterial pressure (MAP)
is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm
Hg. What is the nurses most appropriate action?
A) Position the patient in the high Fowlers position as tolerated.
B) Administer osmotic diuretics as ordered.
C) Participate in interventions to increase cerebral perfusion
pressure.
D) Prepare the patient for craniotomy. - ANSWER ✔✔- C)
Participate in interventions to increase cerebral perfusion
pressure.
The nurse is caring for a patient with increased intracranial
pressure (ICP). The patient has a nursing diagnosis of ineffective
cerebral tissue perfusion. What would be an expected outcome
that the nurse would document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses. -
ANSWER ✔✔- D) Obeys commands with appropriate motor
responses.
A patient exhibiting an altered level of consciousness (LOC) due
to blunt-force trauma to the head is admitted to the ED. The
physician determines the patients injury is causing increased
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intracranial pressure (ICP). The nurse should gauge the patients
LOC on the results of what diagnostic tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination - ANSWER ✔✔- B) Glasgow Coma
Scale
While completing a health history on a patient who has recently
experienced a seizure, the nurse would assess for what
characteristic associated with the postictal state?
A) Epileptic cry
B) Confusion
C) Urinary incontinence
D) Body rigidity - ANSWER ✔✔- B) Confusion
A patient with increased ICP has a ventriculostomy for monitoring
ICP. The nurses most recent assessment reveals that the patient
is now exhibiting nuchal rigidity and photophobia. The nurse
would be correct in suspecting the presence of what
complication?
A) Encephalitis
B) CSF leak
C) Meningitis
D) Catheter occlusion - ANSWER ✔✔- C) Meningitis
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The nurse is caring for a patient who is postoperative following a
craniotomy. When writing the plan of care, the nurse identifies a
diagnosis of deficient fluid volume related to fluid restriction and
osmotic diuretic use. What would be an appropriate intervention
for this diagnosis?
A) Change the patients position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values. - ANSWER ✔✔- B)
Monitor serum electrolytes.
A patient with a documented history of seizure disorder
experiences a generalized seizure. What nursing action is most
appropriate?
A) Restrain the patient to prevent injury.
B) Open the patients jaws to insert an oral airway.
C) Place patient in high Fowlers position.
D) Loosen the patients restrictive clothing. - ANSWER ✔✔- D)
Loosen the patients restrictive clothing.
A patient who has been on long-term phenytoin (Dilantin)
therapy is admitted to the unit. In light of the adverse of effects
of this medication, the nurse should prioritize which of the
following in the patients plan of care?
A) Monitoring of pulse oximetry
B) Administration of a low-protein diet
C) Administration of thorough oral hygiene
MEDICAL SURGICAL NURSING FINAL NEWEST
ACTUAL EXAM COMPLETE 205 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
Management of Patients with Neurologic Dysfunction - ANSWER
✔✔- Management of Patients with Neurologic Dysfunction
A patient is being admitted to the neurologic ICU following an
acute head injury that has resulted in cerebral edema. When
planning this patients care, the nurse would expect to administer
what priority medication?
A) Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix)
C) Mannitol (Osmitrol)
D) Spirolactone (Aldactone) - ANSWER ✔✔- C) Mannitol
(Osmitrol)
The nurse is providing care for a patient who is unconscious.
What nursing intervention takes highest priority?
A) Maintaining accurate records of intake and output
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control - ANSWER ✔✔- B)
Maintaining a patent airway
,2|Page
The nurse is caring for a patient in the ICU who has a brain stem
herniation and who is exhibiting an altered level of consciousness.
Monitoring reveals that the patients mean arterial pressure (MAP)
is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm
Hg. What is the nurses most appropriate action?
A) Position the patient in the high Fowlers position as tolerated.
B) Administer osmotic diuretics as ordered.
C) Participate in interventions to increase cerebral perfusion
pressure.
D) Prepare the patient for craniotomy. - ANSWER ✔✔- C)
Participate in interventions to increase cerebral perfusion
pressure.
The nurse is caring for a patient with increased intracranial
pressure (ICP). The patient has a nursing diagnosis of ineffective
cerebral tissue perfusion. What would be an expected outcome
that the nurse would document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses. -
ANSWER ✔✔- D) Obeys commands with appropriate motor
responses.
A patient exhibiting an altered level of consciousness (LOC) due
to blunt-force trauma to the head is admitted to the ED. The
physician determines the patients injury is causing increased
,3|Page
intracranial pressure (ICP). The nurse should gauge the patients
LOC on the results of what diagnostic tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination - ANSWER ✔✔- B) Glasgow Coma
Scale
While completing a health history on a patient who has recently
experienced a seizure, the nurse would assess for what
characteristic associated with the postictal state?
A) Epileptic cry
B) Confusion
C) Urinary incontinence
D) Body rigidity - ANSWER ✔✔- B) Confusion
A patient with increased ICP has a ventriculostomy for monitoring
ICP. The nurses most recent assessment reveals that the patient
is now exhibiting nuchal rigidity and photophobia. The nurse
would be correct in suspecting the presence of what
complication?
A) Encephalitis
B) CSF leak
C) Meningitis
D) Catheter occlusion - ANSWER ✔✔- C) Meningitis
, 4|Page
The nurse is caring for a patient who is postoperative following a
craniotomy. When writing the plan of care, the nurse identifies a
diagnosis of deficient fluid volume related to fluid restriction and
osmotic diuretic use. What would be an appropriate intervention
for this diagnosis?
A) Change the patients position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values. - ANSWER ✔✔- B)
Monitor serum electrolytes.
A patient with a documented history of seizure disorder
experiences a generalized seizure. What nursing action is most
appropriate?
A) Restrain the patient to prevent injury.
B) Open the patients jaws to insert an oral airway.
C) Place patient in high Fowlers position.
D) Loosen the patients restrictive clothing. - ANSWER ✔✔- D)
Loosen the patients restrictive clothing.
A patient who has been on long-term phenytoin (Dilantin)
therapy is admitted to the unit. In light of the adverse of effects
of this medication, the nurse should prioritize which of the
following in the patients plan of care?
A) Monitoring of pulse oximetry
B) Administration of a low-protein diet
C) Administration of thorough oral hygiene
