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NSG 4100 (AHIII) EXAM 4 TESTBANK 2025
- UNITS 8, 9, 10 QUESTIONS AND
The nurse is caring for a pt w a spinal cord injury notes that the pt is exhibiting
CORRECT ANSWERS early s/s of disuse syndrome. Which of the following is the most appropriate
nursing action?
a. limit the amount of assistance provided w ADLs
b. collaborate w the physical therapist & immobilize the pt's extremities
A nurse on the neurologic unit is providing care for a pt who has spinal cord injury
temporarily
at the level of C4. When planning the pt's care, what aspect of the pt's neurologic
and functional status should the nurse consider? c. increase the frequency of ROM exercises
a. the pt will be unable to use a wheelchair d. educate the pt about the importance of frequent position changes - correct-
answer-C
b. the pt will be unable to swallow food
c. the pt will be continent of urine, but incontinent of bowel
d. the pt will require full assistance fo all aspects of elimination - correct-answer-D
Splints have been ordered for a pt who is at risk of developing foot drop following
a spinal cord injury. The nurse caring for this pt knows that the splints are
removed and reapplied when?
The nurse is providing health education to a pt who has a C6 spinal cord injury. a. at the pt's request
The pt asks why autonomic dysreflexia is considered an emergency. What would
b. each morning and evening
be the nurses best answer?
c. every 2 hours
a. the sudden increase in BP can raise the ICP or rupture a cerebral blood vessel
d. one hour prior to mobility exercises - correct-answer-C
b. the suddenness of the onset of the syndrome tells us the body is struggling to
maintain its nml state
c. autonomic dysreflexia causes permanent damage to delicate nerve fibers that
are healing A pt who is being treated in the hospital for a spinal cord injury is advocating for
d. the sudden, severe headache increases muscle tone and can cause further the removal of his urinary catheter, stating that he wants to try to resume nml
nerve damage - correct-answer-A elimination. What principle should guide the care teams decision regarding this
intervention?
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a. urinary retention can have serious consequences in pt's w SCIs
b. urinary function is permanent lost following and SCI A pt is admitted to the neurologic ICU w a C4 spinal cord injury. When writing the
plan of care for this pt, which of the following nursing diagnoses would the nurse
c. urinary catheters should not remain in place for more than 7 days
prioritize in the immediate care of this pt?
d. overuse of urinary catheters can exacerbate nerve damage - correct-answer-A
a. risk for impaired skin integrity r/t immobility & sensory loss
b. impaired physical mobility r/t loss of motor function
c. ineffective breathing patterns r/t weakness of the intercostal muscles
A pt w spinal cord injury is ready to be discharged home. A family member asks
d. urinary retention to inability to void spontaneously - correct-answer-C
the nurse to review potential complications one more time. What are the
potential complications that should be monitored for in this pt? Select all that
apply:
a. orthostatic hypotension
A pt w possible bacterial meningitis is admitted to the ICU, What assessment
b. autonomic dysreflexia finding would the nurse expect for a pt w this diagnosis?
c. DVT a. pain upon ankle dorsiflexion of the foot
d. salt-wasting syndrome b. neck flexion produces flexion of knees and hips
e. increased ICP - correct-answer-A, B, C c. inability to stand w eyes closed and arms extended w/o swaying
d. numbness & tingling in the lower extremities - correct-answer-B
The nurse recognizes that a pt w a SCI is at risk for muscle spasticity. How can the
nurse best prevent this complication of an SCI?
A pt w Guillain-Barr syndrome has experiences a sharp decline in vital capacity.
a. position the pt in a high fowlers position when in bed What is the nurses most appropriate action?
b. support the knees w a pillow when the pt is in bed a. administer bronchodilators as ordered
c. perform passive ROM exercises as ordered b. remind the pt of the importance of deep breathing and coughing exercises
d. administer NSAIDs as ordered - correct-answer-C c. prepare to assist w intubation
d. administer supplementary oxygen by nasal cannula - correct-answer-C
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c. decreased conduction of impulses in an upper motor neuron lesion
d. a lower motor neuron lesion - correct-answer-D
A male pt presents to clinic c/o headache. The nurse notes that the pt is guarding
his neck and tells the nurse that he has stiffness in the neck area. The nurse
suspects the pt may have meningitis. What is another well-recognized sign of this
infection? A pt w herpes simplex virus encephalitis (HSV) has been admitted to the ICU.
What medication would the nurse expect the physician to order for the treatment
a. negative Brudzinskis sign
of this ds process?
b. positive Kernigs sign
a. cyclosporine (Neoral)
c. hyper patellar reflex
b. acyclovir (Zovirax)
d. sluggish pupil reaction - correct-answer-B
c. cyclobenzaprine (Flexeril)
d. ampicillin (Prinicpen) - correct-answer-B
The nurse is caring for a pt diagnosed w Guillain-Barr syndrome is planning care w
regard to the clinical manifestations associated w this syndrome. The nurses
communication w the pt should reflect the possibility of what sign or sx of the ds? A nurse is planning the care of a 28y/o woman hospitalized w a diagnosis of
myasthenia gravis. What approach would be most appropriate for the care and
a. intermittent hearing loss
scheduling of diagnostic procedures for this pt?
b. tinnitus
a. all at one time, to provide a longer rest period
c. tongue enlargement
b. before meals, to stimulate her appetite
d. vocal paralysis - correct-answer-D
c. in the morning, w frequent rest periods
c. before bedtime, to promote rest - correct-answer-C
The nurse is preparing to provide care for a pt diagnosed w myasthenia gravis. The
nurse should know that the s/s of the ds are the result of what?
The nurse is developing a plan of care for a pt w Guillain-Barr syndrome. Which of
a. genetic dysfunction
the following interventions should the nurse prioritize for this pt?
b. upper and lower neuron lesions
a. using the incentive spirometer as prescribed
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b. maintaining the pt on bed rest A pt is being admitted to the neurologic ICU w suspected herpes simplex virus
encephalitis. What nursing action best addresses the pt's complaints of headache?
c. providing aids to compensate for loss of vision
a. initiating a patient-controlled analgesia (PCA) of morphine sulfate
d. assessing frequently for loss of cognitive function - correct-answer-A
b. administering hydromorphone (Dilaudid) IV as needed
c. dimming the lights and reducing stimulation
d. distracting the pt w activity - correct-answer-C
A 69 y/o pt is brought to the ED bc a family member found him lying on the floor
disoriented and lethargic. The physician suspects bacterial meningitis & admits
the pt to the ICU. The nurse knows that risk factors for an unfavorable outcome
include what? Select all that apply:
A pt is admitted through the ED w suspected St. Louis encephalitis. The unique
a. BP greater than 140/90 mm Hg
clinical feature of St. Louis encephalitis will make what nursing action a priority?
b. HR greater than 120 bpm
a. serial assessments of hemoglobin levels
c. older age
b. blood glucose monitoring
d. low Glasgow scale
c. close monitoring of fluid balance
e. lack of previous immunizations - correct-answer-B, C, D
d. assessment of pain along dermatomes - correct-answer-C
The critical care nurse is caring for a 25 y/o man admitted to the ICU w a brain
You are the clinic nurse caring for a pt w a recent diagnosis of myasthenia gravis.
abscess. What is a priority nursing responsibility in the care of the pt?
The pt has begun treatment w pyridostigmine bromide (Mestinon). What change
a. maintaining the pt's functional independence in status would most clearly suggest a therapeutic benefit of this medication?
b. providing health education a. increased muscle strength
c. monitoring neurologic status closely b. decreased pain
d. promoting mobility - correct-answer-C c. improved GI function
d. improved cognition - correct-answer-A
NSG 4100 (AHIII) EXAM 4 TESTBANK 2025
- UNITS 8, 9, 10 QUESTIONS AND
The nurse is caring for a pt w a spinal cord injury notes that the pt is exhibiting
CORRECT ANSWERS early s/s of disuse syndrome. Which of the following is the most appropriate
nursing action?
a. limit the amount of assistance provided w ADLs
b. collaborate w the physical therapist & immobilize the pt's extremities
A nurse on the neurologic unit is providing care for a pt who has spinal cord injury
temporarily
at the level of C4. When planning the pt's care, what aspect of the pt's neurologic
and functional status should the nurse consider? c. increase the frequency of ROM exercises
a. the pt will be unable to use a wheelchair d. educate the pt about the importance of frequent position changes - correct-
answer-C
b. the pt will be unable to swallow food
c. the pt will be continent of urine, but incontinent of bowel
d. the pt will require full assistance fo all aspects of elimination - correct-answer-D
Splints have been ordered for a pt who is at risk of developing foot drop following
a spinal cord injury. The nurse caring for this pt knows that the splints are
removed and reapplied when?
The nurse is providing health education to a pt who has a C6 spinal cord injury. a. at the pt's request
The pt asks why autonomic dysreflexia is considered an emergency. What would
b. each morning and evening
be the nurses best answer?
c. every 2 hours
a. the sudden increase in BP can raise the ICP or rupture a cerebral blood vessel
d. one hour prior to mobility exercises - correct-answer-C
b. the suddenness of the onset of the syndrome tells us the body is struggling to
maintain its nml state
c. autonomic dysreflexia causes permanent damage to delicate nerve fibers that
are healing A pt who is being treated in the hospital for a spinal cord injury is advocating for
d. the sudden, severe headache increases muscle tone and can cause further the removal of his urinary catheter, stating that he wants to try to resume nml
nerve damage - correct-answer-A elimination. What principle should guide the care teams decision regarding this
intervention?
, Page |3 Page |4
a. urinary retention can have serious consequences in pt's w SCIs
b. urinary function is permanent lost following and SCI A pt is admitted to the neurologic ICU w a C4 spinal cord injury. When writing the
plan of care for this pt, which of the following nursing diagnoses would the nurse
c. urinary catheters should not remain in place for more than 7 days
prioritize in the immediate care of this pt?
d. overuse of urinary catheters can exacerbate nerve damage - correct-answer-A
a. risk for impaired skin integrity r/t immobility & sensory loss
b. impaired physical mobility r/t loss of motor function
c. ineffective breathing patterns r/t weakness of the intercostal muscles
A pt w spinal cord injury is ready to be discharged home. A family member asks
d. urinary retention to inability to void spontaneously - correct-answer-C
the nurse to review potential complications one more time. What are the
potential complications that should be monitored for in this pt? Select all that
apply:
a. orthostatic hypotension
A pt w possible bacterial meningitis is admitted to the ICU, What assessment
b. autonomic dysreflexia finding would the nurse expect for a pt w this diagnosis?
c. DVT a. pain upon ankle dorsiflexion of the foot
d. salt-wasting syndrome b. neck flexion produces flexion of knees and hips
e. increased ICP - correct-answer-A, B, C c. inability to stand w eyes closed and arms extended w/o swaying
d. numbness & tingling in the lower extremities - correct-answer-B
The nurse recognizes that a pt w a SCI is at risk for muscle spasticity. How can the
nurse best prevent this complication of an SCI?
A pt w Guillain-Barr syndrome has experiences a sharp decline in vital capacity.
a. position the pt in a high fowlers position when in bed What is the nurses most appropriate action?
b. support the knees w a pillow when the pt is in bed a. administer bronchodilators as ordered
c. perform passive ROM exercises as ordered b. remind the pt of the importance of deep breathing and coughing exercises
d. administer NSAIDs as ordered - correct-answer-C c. prepare to assist w intubation
d. administer supplementary oxygen by nasal cannula - correct-answer-C
, Page |5 Page |6
c. decreased conduction of impulses in an upper motor neuron lesion
d. a lower motor neuron lesion - correct-answer-D
A male pt presents to clinic c/o headache. The nurse notes that the pt is guarding
his neck and tells the nurse that he has stiffness in the neck area. The nurse
suspects the pt may have meningitis. What is another well-recognized sign of this
infection? A pt w herpes simplex virus encephalitis (HSV) has been admitted to the ICU.
What medication would the nurse expect the physician to order for the treatment
a. negative Brudzinskis sign
of this ds process?
b. positive Kernigs sign
a. cyclosporine (Neoral)
c. hyper patellar reflex
b. acyclovir (Zovirax)
d. sluggish pupil reaction - correct-answer-B
c. cyclobenzaprine (Flexeril)
d. ampicillin (Prinicpen) - correct-answer-B
The nurse is caring for a pt diagnosed w Guillain-Barr syndrome is planning care w
regard to the clinical manifestations associated w this syndrome. The nurses
communication w the pt should reflect the possibility of what sign or sx of the ds? A nurse is planning the care of a 28y/o woman hospitalized w a diagnosis of
myasthenia gravis. What approach would be most appropriate for the care and
a. intermittent hearing loss
scheduling of diagnostic procedures for this pt?
b. tinnitus
a. all at one time, to provide a longer rest period
c. tongue enlargement
b. before meals, to stimulate her appetite
d. vocal paralysis - correct-answer-D
c. in the morning, w frequent rest periods
c. before bedtime, to promote rest - correct-answer-C
The nurse is preparing to provide care for a pt diagnosed w myasthenia gravis. The
nurse should know that the s/s of the ds are the result of what?
The nurse is developing a plan of care for a pt w Guillain-Barr syndrome. Which of
a. genetic dysfunction
the following interventions should the nurse prioritize for this pt?
b. upper and lower neuron lesions
a. using the incentive spirometer as prescribed
, Page |7 Page |8
b. maintaining the pt on bed rest A pt is being admitted to the neurologic ICU w suspected herpes simplex virus
encephalitis. What nursing action best addresses the pt's complaints of headache?
c. providing aids to compensate for loss of vision
a. initiating a patient-controlled analgesia (PCA) of morphine sulfate
d. assessing frequently for loss of cognitive function - correct-answer-A
b. administering hydromorphone (Dilaudid) IV as needed
c. dimming the lights and reducing stimulation
d. distracting the pt w activity - correct-answer-C
A 69 y/o pt is brought to the ED bc a family member found him lying on the floor
disoriented and lethargic. The physician suspects bacterial meningitis & admits
the pt to the ICU. The nurse knows that risk factors for an unfavorable outcome
include what? Select all that apply:
A pt is admitted through the ED w suspected St. Louis encephalitis. The unique
a. BP greater than 140/90 mm Hg
clinical feature of St. Louis encephalitis will make what nursing action a priority?
b. HR greater than 120 bpm
a. serial assessments of hemoglobin levels
c. older age
b. blood glucose monitoring
d. low Glasgow scale
c. close monitoring of fluid balance
e. lack of previous immunizations - correct-answer-B, C, D
d. assessment of pain along dermatomes - correct-answer-C
The critical care nurse is caring for a 25 y/o man admitted to the ICU w a brain
You are the clinic nurse caring for a pt w a recent diagnosis of myasthenia gravis.
abscess. What is a priority nursing responsibility in the care of the pt?
The pt has begun treatment w pyridostigmine bromide (Mestinon). What change
a. maintaining the pt's functional independence in status would most clearly suggest a therapeutic benefit of this medication?
b. providing health education a. increased muscle strength
c. monitoring neurologic status closely b. decreased pain
d. promoting mobility - correct-answer-C c. improved GI function
d. improved cognition - correct-answer-A
