NSG 4100 EXAM 4 Questions with Detailed
Verified Answers
Which of the following is indicative of worsening condition? Ans: Pupil size changing
from 5 to 9mm
(sign of increased ICP)
Which position is best best for patient who is at risk for increased ICP? Ans: Semi
Fowler position
Your patient is S/P craniotomy for tumor removal. Which of the following is indicative
of a complication? Ans: Client states he feels a lot of drainage at the back of his throat
What is a normal reaction of a patient has received a craniotomy? Ans: Eyes that are
swollen post op
Your patient is S/P a craniotomy. Which of the following will need to reported to the
PCP? Ans: BP change from 120/80 to 140/88
Which statement is correct about meningococcal vaccines #1 prevention? Ans:
Recommended between the ages 11-12 and boosters should be recv'd by age 16
Which is appropriate when caring for a patient with encephalitis? Ans: Keeping room
lights dim or off
You are caring for a patient who has had Huntington's for 15 years and is admitted
with pneumonia. Which actions is priority? Ans: Set up bedside humidification
Your patient has been ordered pyridostigmine for myasthenia gravis. You understand
that this medication is used to? Ans: Improve muscle strength
(DO NOT SKIP DOSES OF MEDICATIONS!)
,Your patient is experiencing myasthenia exacerbation related to missed dose of
medication. Which are signs of this crisis state (SATA) Ans: -Difficult speaking
(Dysphonia)
-Extreme muscle weakness
-Shallow, slow RR
-Dyshpagia
*Emergency Prepare for intubation
Your patient is diagnosed with Fibromyalgia. Which is a key feature of this disease?
Ans: Difficulty Sleeping (insomnia)
What education statment is correct when teaching your patient with MS, about activity
and mobility? Ans: Waking improves gait
Your patient sustained a C4 injury. You will expect all of the following EXCEPT? Ans:
Full range of motion
Autonomic dysreflexia is considered an emergency. Why? Ans: Increase in BP can
raise ICP
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
© Get it right 2025 Getaway - Stuvia US All rights reserved
, -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
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 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
© Get it right 2025 Getaway - Stuvia US All rights reserved
Verified Answers
Which of the following is indicative of worsening condition? Ans: Pupil size changing
from 5 to 9mm
(sign of increased ICP)
Which position is best best for patient who is at risk for increased ICP? Ans: Semi
Fowler position
Your patient is S/P craniotomy for tumor removal. Which of the following is indicative
of a complication? Ans: Client states he feels a lot of drainage at the back of his throat
What is a normal reaction of a patient has received a craniotomy? Ans: Eyes that are
swollen post op
Your patient is S/P a craniotomy. Which of the following will need to reported to the
PCP? Ans: BP change from 120/80 to 140/88
Which statement is correct about meningococcal vaccines #1 prevention? Ans:
Recommended between the ages 11-12 and boosters should be recv'd by age 16
Which is appropriate when caring for a patient with encephalitis? Ans: Keeping room
lights dim or off
You are caring for a patient who has had Huntington's for 15 years and is admitted
with pneumonia. Which actions is priority? Ans: Set up bedside humidification
Your patient has been ordered pyridostigmine for myasthenia gravis. You understand
that this medication is used to? Ans: Improve muscle strength
(DO NOT SKIP DOSES OF MEDICATIONS!)
,Your patient is experiencing myasthenia exacerbation related to missed dose of
medication. Which are signs of this crisis state (SATA) Ans: -Difficult speaking
(Dysphonia)
-Extreme muscle weakness
-Shallow, slow RR
-Dyshpagia
*Emergency Prepare for intubation
Your patient is diagnosed with Fibromyalgia. Which is a key feature of this disease?
Ans: Difficulty Sleeping (insomnia)
What education statment is correct when teaching your patient with MS, about activity
and mobility? Ans: Waking improves gait
Your patient sustained a C4 injury. You will expect all of the following EXCEPT? Ans:
Full range of motion
Autonomic dysreflexia is considered an emergency. Why? Ans: Increase in BP can
raise ICP
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
© Get it right 2025 Getaway - Stuvia US All rights reserved
, -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
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 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
© Get it right 2025 Getaway - Stuvia US All rights reserved
