NSG 4100 (AHIII) Exam 4 Post Assessment Actual Final Exam Questions with all Questions Accurately Answered 2024/2025
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Course
NSG 4100
Institution
NSG 4100
NSG 4100 (AHIII) Exam 4 Post Assessment Actual Final Exam Questions with all Questions Accurately Answered 2024/2025
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
...
NSG 4100 (AHIII) Exam 4 Post Assessment Actual
Final Exam Questions with all Questions Accurately
Answered 2024/2025
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 - correct answer 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
C. It indicates paralysis of cranial nerve X
D. It indicates an injury at the midbrain level - correct answer D
Following a traumatic brain injury, a pt has been in a coma for several days. Which of
the following statements is true of this pt's current LOC?
A. The pt occasionally makes incomprehensible sounds
B. The pt's current LOC will likely become a permanent state
C. The pt may occasionally make non purposeful movements
D. The pt is incapable of spontaneous respirations - correct answer C
The nurse is caring for a pt w permanent neurologic impairments resulting from a
traumatic head injury. When working w this pt and family, what mutual goal should be
prioritized?
A. Achieve as high a level of function as possible
B. Enhance the quantity of the pt's life
,C. Teach the family proper care of the pt
D. Provide community assistance - correct answer A
The nurse is caring for a pt whose recent health hx includes an altered LOC. What
should be the nurses first action when assessing this pt?
A. Assessing the pt's verbal response
B. Assessing the pt's ability to follow complex commands
C. Assessing the pt's judgment
D. Assessing the pt's response to pain - correct answer A
The nurse for a pt in a persistent vegetative state is regularly assessing for potential
complications. Complications of neurologic dysfunction for which the nurse should
assess include which of the following? Select all that apply:
A. Contractures
B. Hemorrhage
C. Pressure ulcers
D. Venous thromboembolism
E. Pneumonia - correct answer A, C, D, E
The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to be
ordered to reduce the edema surrounding the tumor?
A. Solumedrol
B. Dextromethorphan
C. Dexamethasone
D. Furosemide - correct answer C
The nurse is caring for a pt who sustained a moderate head injury following a bicycle
accident. The nurses most recent assessment reveals that the pt's respiratory effort has
increased. What is the nurses most appropriate response?
A. Inform the care team and assess for further signs of possible increased ICP
,B. Administer bronchodilators and monitor the pt's LOC
C. Increase the pt's bed height and reassess in 30 mins
D. Administer a bolus of normal line as ordered - correct answer A
A pt has a poor prognosis after being involved in a motor vehicle accident resulting in a
head injury. As the pt's ICP increases and condition worsens, the nurse knows to
assess for indications of approaching death. These indications include which of the
following?
A. Hemiplegia
B. Dry mucous membranes
C. Signs of internal bleeding
D. Loss of brain stem reflexes - correct answer D
When caring for a pt w increased ICP the nurse knows the importance of monitoring for
possible secondary complications, including syndrome of inappropriate antidiuretic
hormone (SIADH). What nursing interventions would the nurse most likely initiate if the
pt developed SIADH?
A. Fluid restriction
B. Transfusion of platelets
C. Transfusion of fresh frozen plasma (FFP)
D. Electrolyte restriction - correct answer A
A pt is recovering from an intracranial surgery performed approximately 24 hrs ago and
is complaining of a headache that the pt rates at 8 on a 10-point pain scale. What
nursing action is most appropriate?
A. Administer morphine sulfate as ordered
B. Reposition the pt in a prone position
C. Apply a hot pack to the pt's scalp
D. Implement distraction techniques - correct answer A
, A pt is postoperative day 1 following intracranial surgery. The nurses assessment
reveals that the LOC is slightly decreased w the day of surgery. What is the nurses best
response to this assessment finding?
A. Recognize that this may represent the peak of post-surgical cerebral edema
B. Alert the surgeon to the possibility of an intracranial hemorrhage
C. Understand that the surgery may have been unsuccessful
D. Recognize the need to refer the pt to the palliative care team - correct answer A
A pt w a cerebral aneurysm exhibits s/s of an increase in ICP. What nursing intervention
would be the most appropriate for this pt?
A. ROM exercises to prevent contractors
B. Encouraging independence w adls to promote recovery
C. Early initiation of physical therapy
D. Absolute bed rest in a quiet, non stimulating environment - correct answer D
A pt has been admitted to the ICU after being recently diagnosed w an aneurysm and
the pt's admission orders include specific aneurysm precautions. What nursing action
will the nurse incorporate into the pt's plan of care?
A. Elevate the HOB to 45 degrees
B. Maintain the pt on complete bed rest
C. Administer enemas when the pt is constipated
D. Avoid use of thigh-high elastic compression stockings - correct answer B
A pt diagnosed w a cerebral aneurysm reports a severe HA to the nurse. What action is
a priority for the nurse?
A. Sit w the pt for a few minutes
B. Administer an analgesic
C. Inform the nurse-manager
D. Call the physician immediately - correct answer D
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