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NSG 4100 (AHIII) Exam 4 Testbank Questions With Complete Solutions
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NSG 4100 (AHIII) Exam 4 Testbank Questions With Complete Solutions
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NSG 4100 (AHIII) Exam 4 Testbank Questions WithComplete Solutions
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. BP greater than 140/90 mm Hg
b. HR greater than 120 bpm
c. older age
d. low Glasgow scale
e. lack of previous immunizations Correct Answer B, C, D
A client recovering from head injury is participating in care. The
nurse determines that the client understands measure to prevent
elevations in ICP if the nurse observes the client doing which of
the following?
a. blowing the nose
b. isometric exercise
c. coughing vigorously
d. healing during repositioning Correct Answer D
A client w Guillain-Barre syndrome has ascending paralysis and
is intubated and receiving mechanical intubation. Which strategy
should the nurse incorporate in the plan of care to help the client
cope w this illness?
a. giving the client full control over care decisions & restricting
visitors
b. providing positive feedback and encouraging active ROM
,c. providing info, giving positive feedback, & encouraging
relaxation
d, proving IV administered sedatives, reducing distractions, &
limiting visitors Correct Answer C
A client w SCI is prone to experience autonomic dysreflexia.
The nurse should include which measures in the plan of care to
minimize the risk of occurrence? Select all that apply:
a. keep the linen wrinkle-free under the client
b. preventing unnecessary pressure on the lower limbs
c. limiting bladder cauterization to once every 12 hrs
d. turning & repositioning the client every 2 hrs
e. ensuring that the client has a bowel movement Correct
Answer A, B, D
A clinic nurse is providing patient education prior to a patients
scheduled palliative radiotherapy to her spine. At the completion
of the patient teaching, the patient continues to ask the same
questions that the nurse has already addressed. What is the
plausible conclusion that the nurse should draw from this?
a. the pt is not listening effectively
b. the pt is noncompliant w the plan of care
c. the pt may have low intelligence quotient or a cognitive
deficit
d. the pt has not achieved the desire learning outcomes Correct
Answer D
A critical care nurse is aware of similarities and differences
between the treatments for different types of shock. Which of
the following interventions is used in all types of shock?
a. agressive hypoglycemic control
,b. administration of hypertonic IV fluids
c. early provision of nutritional support
d. agressive antibiotic therapy Correct Answer C
A critical care nurse is aware of the high incidence of ventilator-
associated pneumonia (VAP) in patients who are being treated
for shock. What intervention should be specified in the patients
plan of care while the patient is ventilated?
a. performing frequent oral care
b. maintinas pt in supine position
c. suctioning pt q15mins unless contraindicated
d. administering prophylactic abx, as ordered Correct Answer
A
A critical care nurse is planning assessments in the knowledge
that patients in shock are vulnerable to developing fluid
replacement complications. For what signs and symptoms
should the nurse monitor the patient? Select all that apply.
a. hypovolemia
b. difficulty breathing
c. cardiovascular overload
d. pulmonary edema
e. hypoglycemia Correct Answer B, C, D
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 Correct Answer C
, A home care nurse is performing a visit to a patients home to
perform wound care following the patients hospital treatment for
severe burns. While interacting with the patient, the nurse
should assess for evidence of what complication?
A) Psychosis
B) Post-traumatic stress disorder
C) Delirium
D) Vascular dementia Correct Answer B
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. negative Brudzinskis sign
b. positive Kernigs sign
c. hyper patellar reflex
d. sluggish pupil reaction Correct Answer B
A neurologic flow chart is often used to document the care of a
pt w a traumatic brain injury. At what point in the pt's care
should the nurse begin to use a neurologic flow chart?
a. when the pt's condition begins to deteriorate
b. as soon as the initial assessment is made
c. at the beginning of each shift
d. when there is a clinically significant change in the pt's
condition Correct Answer B
A nurse caring for a client diagnosed to have head injury. Which
of the following situations needs intervention by the nurse?
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