MSN 377 EXAM 4 QUESTIONS AND ANSWERS LATEST UPDATE 2025
the nurse advises a patient with myasthenia gravis to
A. perform physically demanding activities early in the day
B. anticipate the need for weekly plasmapheresis treatments
C. do frequent weight-bearing exercise to prevent muscle atrophy
D. protect the extremities from injury due to poor sensory perception - Answers A. perform
physically demanding activities early in the day
To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in
the plan of care for a patient who has paraplegia at the T4 level?
A. support selection of a high-protein diet
B. discuss options for sexuality and fertility
C. assist in planning a prescribed bowel program
D. use quad coughing to strengthen cough efforts - Answers C. assist in planning a prescribed
bowel program
which assessment data for a patient who has Guillain-Barre syndrome will require the nurses
most immediate action?
A. the patients sacral area skin is reddened
B. the patient is continuously drooling saliva
C. the patient complains of severe pain in the feet
D. the patients blood pressure is 150/82 - Answers B. the patient is continuously drooling saliva
The nurse has administered a prescribed IV osmotic diuretic to an unconscious patient. which
parameter should the nurse monitor to determine the medications effectiveness?
A. blood pressure
B. intracranial pressure
C. oxygen saturation
D. hemoglobin and hematocrit - Answers B. intracranial pressure
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue
swelling. which nursing intervention will be included in the plan of care?
,A. encourage coughing and deep breathing
B. position the patient with knees and hips flexed
C. keep the head of the bed elevated to 30 degrees
D. cluster nursing interventions to provide rest periods - Answers C. keep the head of the bed
elevated to 30 degrees
Multiple sclerosis - Answers a chronic, progressive degenerative disorder of the CNS.
Characterized by disseminated demyelination of nerve fibers in the brain and spinal cord
myasthenia gravis - Answers an autoimmune disease of the neuromuscular junction.
characterized by the fluctuating weakness of certain skeletal muscle groups, which increases
with muscle use.
Guillain-Barre syndrome - Answers autoimmune condition that causes acute inflammation of
the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in
decreased nerve impulses, loss of reflex response, and sudden muscle weakness
Spinal cord injury - Answers temporary or permanent alteration in the function of the spinal cord,
caused by trauma or damage to the spinal cord
Autonomic hyperreflexia (dysreflexia) - Answers Massive, uncompensated cardiovascular
response to stimulation of the sympathetic nervous system
Stimulation of the sensory receptors below the level of the cord lesion
- HTN, bradycardia, pounding headache
neurogenic shock - Answers unopposed PSNS stimulation and disruption of SNS, causing
bradycardia, vasodilation, and hypotension.
usually occurs with SCI at T6 or above
spinal shock - Answers spinal shock presents with total flaccid paralysis and loss of all reflexes
below the level of injury.
Intracranial pressure - Answers the amount of pressure inside the skull controlled by the three
essential components of pressure in the skull: brain tissue, blood, CSF
A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder.
Which of the following assessment findings should the nurse report to the provider?
A. glasgow coma scale score of 15
, B. intracranial pressure reading of 15mmHg
C. ecchymosis at base of skull
D. clear drainage from nose - Answers D. clear drainage from nose
clear drainage indicates that CSF is leaking from the skill fracture
A nurse in an emergency department is caring for a client who suddenly lost consciousness and
fell in her home. the provider determines that the client had an embolic stroke. Which of the
following medications should the nurse administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - Answers A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
A nurse is assessing a client who had a right hemispheric stoke. Which of the following
neurologic deficits should the nurse expect?
A. aphasia
B. right sided neglect
C. impulsive behavior
D. inability to read - Answers C. impulsive behavior
the nurse should expect impulsive behavior, poor judgment, and lack of awareness of
neurologic deficits
A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level
C5. the client reports a throbbing headache and nausea. the nurse notes facial drooping and a
blood pressure of 220/110. Which of the following actions should the nurse take first?
A. administer hydralazine via IV bolus
B. loosen the clients clothing
the nurse advises a patient with myasthenia gravis to
A. perform physically demanding activities early in the day
B. anticipate the need for weekly plasmapheresis treatments
C. do frequent weight-bearing exercise to prevent muscle atrophy
D. protect the extremities from injury due to poor sensory perception - Answers A. perform
physically demanding activities early in the day
To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in
the plan of care for a patient who has paraplegia at the T4 level?
A. support selection of a high-protein diet
B. discuss options for sexuality and fertility
C. assist in planning a prescribed bowel program
D. use quad coughing to strengthen cough efforts - Answers C. assist in planning a prescribed
bowel program
which assessment data for a patient who has Guillain-Barre syndrome will require the nurses
most immediate action?
A. the patients sacral area skin is reddened
B. the patient is continuously drooling saliva
C. the patient complains of severe pain in the feet
D. the patients blood pressure is 150/82 - Answers B. the patient is continuously drooling saliva
The nurse has administered a prescribed IV osmotic diuretic to an unconscious patient. which
parameter should the nurse monitor to determine the medications effectiveness?
A. blood pressure
B. intracranial pressure
C. oxygen saturation
D. hemoglobin and hematocrit - Answers B. intracranial pressure
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue
swelling. which nursing intervention will be included in the plan of care?
,A. encourage coughing and deep breathing
B. position the patient with knees and hips flexed
C. keep the head of the bed elevated to 30 degrees
D. cluster nursing interventions to provide rest periods - Answers C. keep the head of the bed
elevated to 30 degrees
Multiple sclerosis - Answers a chronic, progressive degenerative disorder of the CNS.
Characterized by disseminated demyelination of nerve fibers in the brain and spinal cord
myasthenia gravis - Answers an autoimmune disease of the neuromuscular junction.
characterized by the fluctuating weakness of certain skeletal muscle groups, which increases
with muscle use.
Guillain-Barre syndrome - Answers autoimmune condition that causes acute inflammation of
the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in
decreased nerve impulses, loss of reflex response, and sudden muscle weakness
Spinal cord injury - Answers temporary or permanent alteration in the function of the spinal cord,
caused by trauma or damage to the spinal cord
Autonomic hyperreflexia (dysreflexia) - Answers Massive, uncompensated cardiovascular
response to stimulation of the sympathetic nervous system
Stimulation of the sensory receptors below the level of the cord lesion
- HTN, bradycardia, pounding headache
neurogenic shock - Answers unopposed PSNS stimulation and disruption of SNS, causing
bradycardia, vasodilation, and hypotension.
usually occurs with SCI at T6 or above
spinal shock - Answers spinal shock presents with total flaccid paralysis and loss of all reflexes
below the level of injury.
Intracranial pressure - Answers the amount of pressure inside the skull controlled by the three
essential components of pressure in the skull: brain tissue, blood, CSF
A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder.
Which of the following assessment findings should the nurse report to the provider?
A. glasgow coma scale score of 15
, B. intracranial pressure reading of 15mmHg
C. ecchymosis at base of skull
D. clear drainage from nose - Answers D. clear drainage from nose
clear drainage indicates that CSF is leaking from the skill fracture
A nurse in an emergency department is caring for a client who suddenly lost consciousness and
fell in her home. the provider determines that the client had an embolic stroke. Which of the
following medications should the nurse administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - Answers A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
A nurse is assessing a client who had a right hemispheric stoke. Which of the following
neurologic deficits should the nurse expect?
A. aphasia
B. right sided neglect
C. impulsive behavior
D. inability to read - Answers C. impulsive behavior
the nurse should expect impulsive behavior, poor judgment, and lack of awareness of
neurologic deficits
A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level
C5. the client reports a throbbing headache and nausea. the nurse notes facial drooping and a
blood pressure of 220/110. Which of the following actions should the nurse take first?
A. administer hydralazine via IV bolus
B. loosen the clients clothing
