ATI MEDSURG 2 NUR 265/ DETAILED
ANSWER KEY NEURO-SHOCK & BURNS
PRACTICE
Course
NUR 265
Neurological Disorders Questions
1. A nurse is assessing a client with increased intracranial pressure (ICP). Which of the
following findings should the nurse report immediately?
A. Decerebrate posturing
B. Pupil size of 3 mm and reactive to light
C. Blood pressure of 140/80 mmHg
D. Glasgow Coma Scale (GCS) score of 14
Answer: A. Decerebrate posturing
Rationale: Decerebrate posturing (extension of arms, pronation of forearms, plantar flexion)
indicates severe brainstem damage and worsening ICP. It requires immediate intervention to
prevent brain herniation. Other options (B, C, and D) do not indicate immediate deterioration.
2. A client with a recent ischemic stroke is prescribed tissue plasminogen activator (tPA).
Which of the following is a contraindication to this therapy?
A. Blood pressure of 160/90 mmHg
B. Stroke symptoms present for 2 hours
C. Platelet count of 50,000/mm³
D. History of type 2 diabetes mellitus
Answer: C. Platelet count of 50,000/mm³
Rationale: A low platelet count increases bleeding risk, making thrombolytic therapy unsafe.
Blood pressure (A) can be managed before administration, symptom duration (B) is within the
treatment window, and diabetes (D) is not a contraindication.
3. A client with Guillain-Barré syndrome is at risk for which life-threatening complication?
A. Myasthenic crisis
, B. Respiratory failure
C. Cardiac dysrhythmias
D. Seizures
Answer: B. Respiratory failure
Rationale: Guillain-Barré syndrome causes ascending paralysis, which can reach the respiratory
muscles, leading to respiratory failure. Myasthenic crisis (A) occurs in myasthenia gravis, cardiac
dysrhythmias (C) are possible but not the primary concern, and seizures (D) are not typical.
4. A client with a spinal cord injury at T4 suddenly experiences a severe headache,
hypertension (BP 200/110), and bradycardia. What is the priority intervention?
A. Administer IV labetalol
B. Lower the head of the bed
C. Check for a noxious stimulus
D. Call the healthcare provider immediately
Answer: C. Check for a noxious stimulus
Rationale: These are signs of autonomic dysreflexia, a medical emergency triggered by stimuli
like a full bladder or fecal impaction. The first action is to relieve the cause. IV antihypertensives
(A) may be used if BP remains high. Lowering the head (B) worsens ICP. Calling the provider (D)
is important but not the immediate action.
5. A nurse is caring for a client with Parkinson’s disease. Which of the following should the
nurse include in the plan of care?
A. Encourage a diet high in protein with levodopa
B. Teach the client to rock back and forth to initiate movement
C. Instruct the client to walk with a wide-based gait
D. Place the client on bedrest to prevent falls
Answer: B. Teach the client to rock back and forth to initiate movement
Rationale: Clients with Parkinson’s have bradykinesia and freezing episodes. Rocking helps
initiate movement. High-protein diets (A) interfere with levodopa absorption. Walking with a
wide-based gait (C) is more relevant to cerebellar ataxia. Bedrest (D) leads to deconditioning.
,Shock Questions
6. Which of the following assessment findings indicates that a client is progressing from
compensated to decompensated (progressive) shock?
A. BP 120/80 mmHg
B. Increased urine output
C. Lethargy and cold, clammy skin
D. Bounding peripheral pulses
Answer: C. Lethargy and cold, clammy skin
Rationale: In decompensated shock, organ perfusion decreases, leading to altered mental
status and cold, clammy skin. BP (A) is maintained in early stages. Urine output (B) decreases,
not increases. Bounding pulses (D) are seen in early septic shock.
7. A client in septic shock has a serum lactate level of 5 mmol/L. What is the priority
intervention?
A. Administer IV antibiotics
B. Initiate a fluid bolus
C. Obtain a central venous pressure (CVP) reading
D. Start norepinephrine infusion
Answer: B. Initiate a fluid bolus
Rationale: A lactate > 4 mmol/L indicates tissue hypoperfusion. Fluid resuscitation is the
priority to improve perfusion. IV antibiotics (A) are also needed but after fluids. CVP (C) helps
guide resuscitation but is not first. Vasopressors (D) are added if fluids fail.
Burns Questions
8. A client with severe burns is at risk for which electrolyte imbalance in the first 24 hours?
A. Hyperkalemia
B. Hypokalemia
C. Hypocalcemia
, D. Hypernatremia
Answer: A. Hyperkalemia
Rationale: Cellular damage releases potassium, causing hyperkalemia. Hypokalemia (B) can
occur later due to fluid shifts. Hypocalcemia (C) is more common in massive blood transfusions.
Hypernatremia (D) occurs later with fluid resuscitation imbalances.
9. A client with burns over 50% of the body is receiving fluid resuscitation. Which finding
indicates adequate fluid resuscitation?
A. Urine output of 50 mL/hr
B. Heart rate of 120 bpm
C. Blood pressure of 90/50 mmHg
D. Serum sodium of 120 mEq/L
Answer: A. Urine output of 50 mL/hr
Rationale: Urine output > 30 mL/hr indicates adequate perfusion. A high heart rate (B)
suggests hypovolemia. Low BP (C) means fluid resuscitation is inadequate. Hyponatremia (D)
may result from fluid shifts but is not the primary indicator.
10. A nurse is planning care for a client with an electrical burn. Which assessment is the
priority?
A. Cardiac monitoring
B. Fluid balance
C. Pain control
D. Wound care
Answer: A. Cardiac monitoring
Rationale: Electrical burns can cause life-threatening arrhythmias due to myocardial damage.
Fluid balance (B) is important but not the immediate priority. Pain control (C) and wound care
(D) are necessary but secondary to cardiac stability.
Burns Questions
11. A client with a severe burn is at risk for which complication in the emergent phase?
A. Hypernatremia
ANSWER KEY NEURO-SHOCK & BURNS
PRACTICE
Course
NUR 265
Neurological Disorders Questions
1. A nurse is assessing a client with increased intracranial pressure (ICP). Which of the
following findings should the nurse report immediately?
A. Decerebrate posturing
B. Pupil size of 3 mm and reactive to light
C. Blood pressure of 140/80 mmHg
D. Glasgow Coma Scale (GCS) score of 14
Answer: A. Decerebrate posturing
Rationale: Decerebrate posturing (extension of arms, pronation of forearms, plantar flexion)
indicates severe brainstem damage and worsening ICP. It requires immediate intervention to
prevent brain herniation. Other options (B, C, and D) do not indicate immediate deterioration.
2. A client with a recent ischemic stroke is prescribed tissue plasminogen activator (tPA).
Which of the following is a contraindication to this therapy?
A. Blood pressure of 160/90 mmHg
B. Stroke symptoms present for 2 hours
C. Platelet count of 50,000/mm³
D. History of type 2 diabetes mellitus
Answer: C. Platelet count of 50,000/mm³
Rationale: A low platelet count increases bleeding risk, making thrombolytic therapy unsafe.
Blood pressure (A) can be managed before administration, symptom duration (B) is within the
treatment window, and diabetes (D) is not a contraindication.
3. A client with Guillain-Barré syndrome is at risk for which life-threatening complication?
A. Myasthenic crisis
, B. Respiratory failure
C. Cardiac dysrhythmias
D. Seizures
Answer: B. Respiratory failure
Rationale: Guillain-Barré syndrome causes ascending paralysis, which can reach the respiratory
muscles, leading to respiratory failure. Myasthenic crisis (A) occurs in myasthenia gravis, cardiac
dysrhythmias (C) are possible but not the primary concern, and seizures (D) are not typical.
4. A client with a spinal cord injury at T4 suddenly experiences a severe headache,
hypertension (BP 200/110), and bradycardia. What is the priority intervention?
A. Administer IV labetalol
B. Lower the head of the bed
C. Check for a noxious stimulus
D. Call the healthcare provider immediately
Answer: C. Check for a noxious stimulus
Rationale: These are signs of autonomic dysreflexia, a medical emergency triggered by stimuli
like a full bladder or fecal impaction. The first action is to relieve the cause. IV antihypertensives
(A) may be used if BP remains high. Lowering the head (B) worsens ICP. Calling the provider (D)
is important but not the immediate action.
5. A nurse is caring for a client with Parkinson’s disease. Which of the following should the
nurse include in the plan of care?
A. Encourage a diet high in protein with levodopa
B. Teach the client to rock back and forth to initiate movement
C. Instruct the client to walk with a wide-based gait
D. Place the client on bedrest to prevent falls
Answer: B. Teach the client to rock back and forth to initiate movement
Rationale: Clients with Parkinson’s have bradykinesia and freezing episodes. Rocking helps
initiate movement. High-protein diets (A) interfere with levodopa absorption. Walking with a
wide-based gait (C) is more relevant to cerebellar ataxia. Bedrest (D) leads to deconditioning.
,Shock Questions
6. Which of the following assessment findings indicates that a client is progressing from
compensated to decompensated (progressive) shock?
A. BP 120/80 mmHg
B. Increased urine output
C. Lethargy and cold, clammy skin
D. Bounding peripheral pulses
Answer: C. Lethargy and cold, clammy skin
Rationale: In decompensated shock, organ perfusion decreases, leading to altered mental
status and cold, clammy skin. BP (A) is maintained in early stages. Urine output (B) decreases,
not increases. Bounding pulses (D) are seen in early septic shock.
7. A client in septic shock has a serum lactate level of 5 mmol/L. What is the priority
intervention?
A. Administer IV antibiotics
B. Initiate a fluid bolus
C. Obtain a central venous pressure (CVP) reading
D. Start norepinephrine infusion
Answer: B. Initiate a fluid bolus
Rationale: A lactate > 4 mmol/L indicates tissue hypoperfusion. Fluid resuscitation is the
priority to improve perfusion. IV antibiotics (A) are also needed but after fluids. CVP (C) helps
guide resuscitation but is not first. Vasopressors (D) are added if fluids fail.
Burns Questions
8. A client with severe burns is at risk for which electrolyte imbalance in the first 24 hours?
A. Hyperkalemia
B. Hypokalemia
C. Hypocalcemia
, D. Hypernatremia
Answer: A. Hyperkalemia
Rationale: Cellular damage releases potassium, causing hyperkalemia. Hypokalemia (B) can
occur later due to fluid shifts. Hypocalcemia (C) is more common in massive blood transfusions.
Hypernatremia (D) occurs later with fluid resuscitation imbalances.
9. A client with burns over 50% of the body is receiving fluid resuscitation. Which finding
indicates adequate fluid resuscitation?
A. Urine output of 50 mL/hr
B. Heart rate of 120 bpm
C. Blood pressure of 90/50 mmHg
D. Serum sodium of 120 mEq/L
Answer: A. Urine output of 50 mL/hr
Rationale: Urine output > 30 mL/hr indicates adequate perfusion. A high heart rate (B)
suggests hypovolemia. Low BP (C) means fluid resuscitation is inadequate. Hyponatremia (D)
may result from fluid shifts but is not the primary indicator.
10. A nurse is planning care for a client with an electrical burn. Which assessment is the
priority?
A. Cardiac monitoring
B. Fluid balance
C. Pain control
D. Wound care
Answer: A. Cardiac monitoring
Rationale: Electrical burns can cause life-threatening arrhythmias due to myocardial damage.
Fluid balance (B) is important but not the immediate priority. Pain control (C) and wound care
(D) are necessary but secondary to cardiac stability.
Burns Questions
11. A client with a severe burn is at risk for which complication in the emergent phase?
A. Hypernatremia
