NSG 4100 (AHIII) Exam 4 Testbank Questions
with Detailed Verified Answers
The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites,
including the neck & upper back & knees. The pt also reports non-refreshing sleep,
depression, & being anxious when dealing w multiple tasks. The nurse should teach this
pt about what treatments? Select all that apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern Ans: B, D, E
The nurse caring for a client w a head injury would recognize which assessment finding
as early signs of increased ICP? Select all that apply:
a. Kussmaul breathing
b. Projectile vomiting
c. Weakness in one extremity
d. Headache not aggravated by movement of straining
e. Decreased urine output
f. Papilledema Ans: A, C, D
A nurse caring for a client diagnosed to have head injury. Which of the following
situations needs intervention by the nurse?
,a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3 hours in the
evening
d. The head of bed is elevated at 30 degree angle Ans: C
The critical care nurse is caring for a client w a head injury secondary to a motorcycle
accident who, on morning rounds, is responsive to painful stimulus and assumes
decorticate posturing. Two hours later, which data would warrant immediate
intervention by the nurse?
a. The client has purposeful movement when the nurse rubs the sternum
b. The client extends the upper and lower extremities in response to painful stimuli
c. The client is aimlessly thrashing in the bed when a noxious stimuli is applied Ans: B
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 Ans: 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
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,c. Omitting doses of medication
d. Intake of fatty foods Ans: 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) Ans: 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 Ans: 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
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, c. administration of thorough oral hygiene
d. fluid restriction as ordered Ans: 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) Ans: 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 Ans: 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
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with Detailed Verified Answers
The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites,
including the neck & upper back & knees. The pt also reports non-refreshing sleep,
depression, & being anxious when dealing w multiple tasks. The nurse should teach this
pt about what treatments? Select all that apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern Ans: B, D, E
The nurse caring for a client w a head injury would recognize which assessment finding
as early signs of increased ICP? Select all that apply:
a. Kussmaul breathing
b. Projectile vomiting
c. Weakness in one extremity
d. Headache not aggravated by movement of straining
e. Decreased urine output
f. Papilledema Ans: A, C, D
A nurse caring for a client diagnosed to have head injury. Which of the following
situations needs intervention by the nurse?
,a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3 hours in the
evening
d. The head of bed is elevated at 30 degree angle Ans: C
The critical care nurse is caring for a client w a head injury secondary to a motorcycle
accident who, on morning rounds, is responsive to painful stimulus and assumes
decorticate posturing. Two hours later, which data would warrant immediate
intervention by the nurse?
a. The client has purposeful movement when the nurse rubs the sternum
b. The client extends the upper and lower extremities in response to painful stimuli
c. The client is aimlessly thrashing in the bed when a noxious stimuli is applied Ans: B
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 Ans: 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
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,c. Omitting doses of medication
d. Intake of fatty foods Ans: 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) Ans: 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 Ans: 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
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, c. administration of thorough oral hygiene
d. fluid restriction as ordered Ans: 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) Ans: 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 Ans: 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
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