NSG 4100 (AHIII) Exam 4 Testbank ACTUAL EXAM
(TESTING REAL EXAM QUESTIONS) AND VERIFIED
ANSWERS (MULTIPLE CHOICES) |COMPLETE
SOLUTIONS |A+ GRADED |100% CORRECT!!
The nurse is caring for clients in the ED. Which client should the nurse assess first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ✔✔A
A female pt has experienced an episode of myasthenic crisis. The nurse would assess whether
the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ✔✔C
A pt is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this pt's care, the nurse would expect to administer what
priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
b. Furosemide (Lasix)
c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ✔✔C
,The nurse is caring for a pt who is postoperative following a craniotomy. When writing the plan
of care, the nurse identifies a diagnosis of deficient fluid volume r/t fluid restriction & osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - ✔✔B
A pt 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 pt's plan of care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - ✔✔C
A nurse is admitting a pt w a severe migraine headache and a hx of acute coronary syndrome.
What migraine medication would the nurse question for this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - ✔✔C
The nurse is caring for a pt w increased ICP. The pt has a nursing dx of ineffective cerebral tissue
perfusion. What would be an expected outcome that the nurse would document for this
diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
c. pays attention to grooming
,d. obeys commands w appropriate motor responses - ✔✔D
A pt exhibiting an altered LOC due to blunt-force trauma to the head is admitted to the ED. The
physician determines the pt's injury is causing increased ICP. The nurse should gauge the pt's
LOC on the results of what diagnostic tool?
a. Monro-Kellie hypothesis
b. Glasgow Coma Scale
c. Cranial nerve function
d. mental status examination - ✔✔B
A pt w increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the pt 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 - ✔✔C
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is
contraindicated in this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - ✔✔B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care plan
should specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
, c. projectile vomiting
d. loss of corneal reflex - ✔✔A
The neurologic ICU nurse is admitting a pt following a craniotomy using the supratentorial
approach. How should the nurse best position the pt?
a. position the pt supine
b. maintain HOB elevated at 30-45 degrees
c. position pt in prone position
d. maintain bed in Trendelenberg position - ✔✔B
A pt has developed diabetes insipidness after having increased ICP following head trauma.
What nursing assessment best addresses this complication?
a. vigilant monitoring of fluid balance
b. continuous BP monitoring
c. serial arterial blood gases (ABGs)
d. monitoring of the pt's airway for patency - ✔✔A
What would the nurse suspect when hourly assessment of UO on a pt postcrainiotomy exhibits
a urine output from a catheter of 1,500mL for 2 consecutive hours?
a. ruching syndrom
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - ✔✔D
During the exam of an unconscious pt, the nurse observes that the pt's pupils are fixed and
dilated. What is the most plausible clinical significant of the nurses finding?
a. it suggests onset of metabolic problems
b. it indicates paralysis on the right side of the body
(TESTING REAL EXAM QUESTIONS) AND VERIFIED
ANSWERS (MULTIPLE CHOICES) |COMPLETE
SOLUTIONS |A+ GRADED |100% CORRECT!!
The nurse is caring for clients in the ED. Which client should the nurse assess first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ✔✔A
A female pt has experienced an episode of myasthenic crisis. The nurse would assess whether
the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ✔✔C
A pt is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this pt's care, the nurse would expect to administer what
priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
b. Furosemide (Lasix)
c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ✔✔C
,The nurse is caring for a pt who is postoperative following a craniotomy. When writing the plan
of care, the nurse identifies a diagnosis of deficient fluid volume r/t fluid restriction & osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - ✔✔B
A pt 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 pt's plan of care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - ✔✔C
A nurse is admitting a pt w a severe migraine headache and a hx of acute coronary syndrome.
What migraine medication would the nurse question for this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - ✔✔C
The nurse is caring for a pt w increased ICP. The pt has a nursing dx of ineffective cerebral tissue
perfusion. What would be an expected outcome that the nurse would document for this
diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
c. pays attention to grooming
,d. obeys commands w appropriate motor responses - ✔✔D
A pt exhibiting an altered LOC due to blunt-force trauma to the head is admitted to the ED. The
physician determines the pt's injury is causing increased ICP. The nurse should gauge the pt's
LOC on the results of what diagnostic tool?
a. Monro-Kellie hypothesis
b. Glasgow Coma Scale
c. Cranial nerve function
d. mental status examination - ✔✔B
A pt w increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the pt 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 - ✔✔C
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is
contraindicated in this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - ✔✔B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care plan
should specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
, c. projectile vomiting
d. loss of corneal reflex - ✔✔A
The neurologic ICU nurse is admitting a pt following a craniotomy using the supratentorial
approach. How should the nurse best position the pt?
a. position the pt supine
b. maintain HOB elevated at 30-45 degrees
c. position pt in prone position
d. maintain bed in Trendelenberg position - ✔✔B
A pt has developed diabetes insipidness after having increased ICP following head trauma.
What nursing assessment best addresses this complication?
a. vigilant monitoring of fluid balance
b. continuous BP monitoring
c. serial arterial blood gases (ABGs)
d. monitoring of the pt's airway for patency - ✔✔A
What would the nurse suspect when hourly assessment of UO on a pt postcrainiotomy exhibits
a urine output from a catheter of 1,500mL for 2 consecutive hours?
a. ruching syndrom
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - ✔✔D
During the exam of an unconscious pt, the nurse observes that the pt's pupils are fixed and
dilated. What is the most plausible clinical significant of the nurses finding?
a. it suggests onset of metabolic problems
b. it indicates paralysis on the right side of the body
