NURS 321 Final Exam | Comprehensive Medical-Surgical Nursing Autoimmune
Disorders, Increased ICP & Intracranial Disorders, Inflammatory & Mobility
Disorders, and Sensory Perception
Question 1
Which of the following would be appropriate to utilize in diagnosing increased Intracranial
Pressure (ICP)?
A) Electrocardiogram (ECG) and chest X-ray
B) CT Scan of the brain, neurological assessment, and ventriculostomy
C) Abdominal ultrasound and serum creatinine
D) Lumbar puncture as the primary and first diagnostic tool
E) Skin biopsy and Electromyography (EMG)
Correct Answer: B) CT Scan of the brain, neurological assessment, and ventriculostomy
Rationale: Diagnosing increased ICP requires a combination of imaging, clinical assessment,
and direct measurement. A CT scan helps identify the underlying cause (e.g., tumor,
hemorrhage, or edema). A systematic neurological assessment (including the Glasgow
Coma Scale) detects clinical changes in consciousness or motor function. A ventriculostomy
is considered the "gold standard" because it allows for both the continuous monitoring of
pressure and the therapeutic drainage of cerebrospinal fluid (CSF). While a cranial X-ray
can show fractures, it does not diagnose pressure levels, and a lumbar puncture is often
contraindicated in high ICP due to the risk of brain herniation.
Question 2
In assessing a patient with scleroderma for a pending renal crisis, which findings require
immediate intervention by the nurse?
A) Significant weight gain, Blood pressure 174/100 mm Hg, and Creatinine 1.9 mg/dL
B) Clear urine output and BUN of 15 mg/dL
C) Decreased skin thickness and increased joint range of motion
D) Hypotension and bradycardia
E) Increased appetite and respiratory rate of 16 breaths per minute
Correct Answer: A) Significant weight gain, Blood pressure 174/100 mm Hg, and Creatinine
1.9 mg/dL
Rationale: Scleroderma (systemic sclerosis) can lead to a life-threatening renal crisis
characterized by the sudden onset of severe hypertension and rapidly progressive renal
failure. Significant weight gain indicates fluid retention, an elevated BP (174/100) indicates
vascular resistance and renal distress, and an elevated creatinine (1.9 mg/dL) reflects
impaired glomerular filtration. Clear urine output and a normal BUN (15 mg/dL) are
reassuring signs, not indicators of crisis.
Question 3
Which statement is true regarding the pathophysiology of Myasthenia Gravis (MG)?
A) There is a massive overproduction of norepinephrine at the neuromuscular junction.
, 2
B) The myelin sheath of the peripheral nerves is destroyed by T-cells.
C) Sensitivity to normal amounts of acetylcholine (ACh) is diminished due to receptor
destruction.
D) The primary defect is a lack of production of acetylcholine in the brain.
E) Motor neurons in the ventral horn of the spinal cord undergo rapid degeneration.
Correct Answer: D) Sensitivity to normal amounts of acetylcholine is diminished.
Rationale: Myasthenia Gravis is an autoimmune disease where antibodies attack and
destroy acetylcholine receptors (AChR) at the postsynaptic neuromuscular junction.
Because there are fewer available receptors, the muscle becomes less sensitive to ACh,
leading to hallmark muscle weakness and fatigability. The amount of ACh released is
usually normal, but the "receiving" hardware is damaged.
Question 4
Which type of surgery is most commonly performed to improve long-term outcomes for a patient
diagnosed with Myasthenia Gravis (MG)?
A) Microvascular decompression
B) Thymectomy
C) Percutaneous rhizotomy
D) Stereotactic radiosurgery
E) Ventriculoperitoneal shunt placement
Correct Answer: B) Thymectomy
Rationale: The thymus gland is often abnormal in patients with MG and is believed to be
the site of antibody production against ACh receptors. A thymectomy (surgical removal of
the thymus) is frequently performed, especially in younger patients or those with a
thymoma, to induce clinical remission or reduce the required dose of immunosuppressive
medications.
Question 5
Which nursing intervention is essential when providing nutritional care for a patient with
Myasthenia Gravis (MG)?
A) Keeping the head of the bed flat during and after meals
B) Providing large meals when the patient is most fatigued at the end of the day
C) Offering soft foods and thickened liquids as recommended by a speech therapist
D) Encouraging the patient to talk extensively during meals to maintain socialization
E) Administering anticholinesterase medications exactly 2 hours after eating
Correct Answer: C) Offering soft foods and thickened liquids per the order of the speech
therapist
Rationale: Patients with MG often suffer from bulbar weakness, affecting the muscles of
chewing and swallowing (dysphagia). Soft foods and thickened liquids reduce the risk of
, 3
aspiration. Meals should be timed to coincide with the "peak" action of anticholinesterase
medications (e.g., pyridostigmine) to ensure maximum muscle strength during swallowing.
The head of the bed should be elevated, not lowered.
Question 6
A nurse is teaching about nursing actions for a patient with Guillain-Barré Syndrome (GBS).
Which statement by the nurse-trainee indicates a need for further teaching?
A) "I will establish a clear method of communication for the patient."
B) "I will not offer any kind of diversions or entertainment to the patient."
C) "I will frequently reposition the patient to prevent pressure injuries."
D) "I will discuss the use of nonopioid analgesics with the healthcare provider."
E) "I will monitor the patient's vital capacity and respiratory effort closely."
Correct Answer: B) "Do not offer any kind of diversions to the patient."
Rationale: Patients with GBS are often cognitively intact but physically paralyzed and
potentially intubated. This leads to high levels of anxiety and sensory deprivation.
Diversional activities (music, television, reading) are essential for psychological well-being.
Communication methods, frequent repositioning, and pain management are all standard
and correct aspects of GBS care.
Question 7
Which clinical feature is a hallmark sign of a cholinergic crisis in a patient with Myasthenia
Gravis (MG)?
A) Severe dry mouth and constipation
B) Tachycardia and hypertension
C) Excessive bronchial secretions and miosis
D) Extreme muscle rigidity and high fever
E) Improved muscle strength after resting
Correct Answer: C) Excessive secretions
Rationale: A cholinergic crisis is caused by an overabundance of acetylcholine, usually due
to an overdose of anticholinesterase medication. This results in "SLUDGE" symptoms:
Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress, and Emesis.
Excessive secretions and bradycardia are critical signs that differentiate it from a
myasthenic crisis.
Question 8
Which of the following describes the underlying cause of a cholinergic crisis?
A) An acute lack of acetylcholine at the synaptic cleft.
B) A rapid infection of the cerebrospinal fluid.
C) A sudden withdrawal from corticosteroid therapy.
, 4
D) Excessive intake of anticholinesterase medication.
E) A secondary reaction to a viral immunization.
Correct Answer: D) It is caused by an excessive intake of anticholinesterase medication.
Rationale: When a patient takes too much anticholinesterase medication (like
pyridostigmine), the acetylcholine remains at the junction too long, causing a "depolarizing
block" of the muscle. This leads to weakness that can mimic the disease itself, but is
accompanied by parasympathetic over-stimulation (secretions, diarrhea, bradycardia).
Question 9
Which of the following are clinical features associated with a Myasthenic Crisis?
A) Bradycardia and excessive sweating
B) Tachycardia, pale/cool skin, and flaccid muscles
C) Pinpoint pupils and diarrhea
D) Increased salivation and muscle twitching
E) Hypertension and warm, flushed skin
Correct Answer: B) Tachycardia, pale/cool skin, and flaccid muscles
Rationale: A myasthenic crisis is caused by "not enough" medication or an exacerbation of
the disease (often triggered by infection). The patient experiences severe muscle weakness
and respiratory distress. The body compensates for the stress with a sympathetic response,
leading to tachycardia and cool skin. In contrast, bradycardia and secretions are seen in a
cholinergic crisis.
Question 10
Which diagnostic test is used to rapidly distinguish between a myasthenic crisis and a cholinergic
crisis?
A) Repetitive nerve stimulation (RNS)
B) Tensilon (Edrophonium) test
C) Chest CT scan to look for a thymoma
D) Lumbar puncture for protein analysis
E) Serum acetylcholine receptor antibody titer
Correct Answer: B) Tensilon test
Rationale: The Tensilon test involves injecting edrophonium, a short-acting
acetylcholinesterase inhibitor. If the patient's strength improves significantly, they are in a
myasthenic crisis (not enough ACh). If their strength worsens or they develop more
secretions/twitching, they are likely in a cholinergic crisis (too much ACh). Atropine must
be available at the bedside during this test to reverse potential cholinergic effects.
Question 11
The nurse is caring for a patient with Amyotrophic Lateral Sclerosis (ALS). Which complication
Disorders, Increased ICP & Intracranial Disorders, Inflammatory & Mobility
Disorders, and Sensory Perception
Question 1
Which of the following would be appropriate to utilize in diagnosing increased Intracranial
Pressure (ICP)?
A) Electrocardiogram (ECG) and chest X-ray
B) CT Scan of the brain, neurological assessment, and ventriculostomy
C) Abdominal ultrasound and serum creatinine
D) Lumbar puncture as the primary and first diagnostic tool
E) Skin biopsy and Electromyography (EMG)
Correct Answer: B) CT Scan of the brain, neurological assessment, and ventriculostomy
Rationale: Diagnosing increased ICP requires a combination of imaging, clinical assessment,
and direct measurement. A CT scan helps identify the underlying cause (e.g., tumor,
hemorrhage, or edema). A systematic neurological assessment (including the Glasgow
Coma Scale) detects clinical changes in consciousness or motor function. A ventriculostomy
is considered the "gold standard" because it allows for both the continuous monitoring of
pressure and the therapeutic drainage of cerebrospinal fluid (CSF). While a cranial X-ray
can show fractures, it does not diagnose pressure levels, and a lumbar puncture is often
contraindicated in high ICP due to the risk of brain herniation.
Question 2
In assessing a patient with scleroderma for a pending renal crisis, which findings require
immediate intervention by the nurse?
A) Significant weight gain, Blood pressure 174/100 mm Hg, and Creatinine 1.9 mg/dL
B) Clear urine output and BUN of 15 mg/dL
C) Decreased skin thickness and increased joint range of motion
D) Hypotension and bradycardia
E) Increased appetite and respiratory rate of 16 breaths per minute
Correct Answer: A) Significant weight gain, Blood pressure 174/100 mm Hg, and Creatinine
1.9 mg/dL
Rationale: Scleroderma (systemic sclerosis) can lead to a life-threatening renal crisis
characterized by the sudden onset of severe hypertension and rapidly progressive renal
failure. Significant weight gain indicates fluid retention, an elevated BP (174/100) indicates
vascular resistance and renal distress, and an elevated creatinine (1.9 mg/dL) reflects
impaired glomerular filtration. Clear urine output and a normal BUN (15 mg/dL) are
reassuring signs, not indicators of crisis.
Question 3
Which statement is true regarding the pathophysiology of Myasthenia Gravis (MG)?
A) There is a massive overproduction of norepinephrine at the neuromuscular junction.
, 2
B) The myelin sheath of the peripheral nerves is destroyed by T-cells.
C) Sensitivity to normal amounts of acetylcholine (ACh) is diminished due to receptor
destruction.
D) The primary defect is a lack of production of acetylcholine in the brain.
E) Motor neurons in the ventral horn of the spinal cord undergo rapid degeneration.
Correct Answer: D) Sensitivity to normal amounts of acetylcholine is diminished.
Rationale: Myasthenia Gravis is an autoimmune disease where antibodies attack and
destroy acetylcholine receptors (AChR) at the postsynaptic neuromuscular junction.
Because there are fewer available receptors, the muscle becomes less sensitive to ACh,
leading to hallmark muscle weakness and fatigability. The amount of ACh released is
usually normal, but the "receiving" hardware is damaged.
Question 4
Which type of surgery is most commonly performed to improve long-term outcomes for a patient
diagnosed with Myasthenia Gravis (MG)?
A) Microvascular decompression
B) Thymectomy
C) Percutaneous rhizotomy
D) Stereotactic radiosurgery
E) Ventriculoperitoneal shunt placement
Correct Answer: B) Thymectomy
Rationale: The thymus gland is often abnormal in patients with MG and is believed to be
the site of antibody production against ACh receptors. A thymectomy (surgical removal of
the thymus) is frequently performed, especially in younger patients or those with a
thymoma, to induce clinical remission or reduce the required dose of immunosuppressive
medications.
Question 5
Which nursing intervention is essential when providing nutritional care for a patient with
Myasthenia Gravis (MG)?
A) Keeping the head of the bed flat during and after meals
B) Providing large meals when the patient is most fatigued at the end of the day
C) Offering soft foods and thickened liquids as recommended by a speech therapist
D) Encouraging the patient to talk extensively during meals to maintain socialization
E) Administering anticholinesterase medications exactly 2 hours after eating
Correct Answer: C) Offering soft foods and thickened liquids per the order of the speech
therapist
Rationale: Patients with MG often suffer from bulbar weakness, affecting the muscles of
chewing and swallowing (dysphagia). Soft foods and thickened liquids reduce the risk of
, 3
aspiration. Meals should be timed to coincide with the "peak" action of anticholinesterase
medications (e.g., pyridostigmine) to ensure maximum muscle strength during swallowing.
The head of the bed should be elevated, not lowered.
Question 6
A nurse is teaching about nursing actions for a patient with Guillain-Barré Syndrome (GBS).
Which statement by the nurse-trainee indicates a need for further teaching?
A) "I will establish a clear method of communication for the patient."
B) "I will not offer any kind of diversions or entertainment to the patient."
C) "I will frequently reposition the patient to prevent pressure injuries."
D) "I will discuss the use of nonopioid analgesics with the healthcare provider."
E) "I will monitor the patient's vital capacity and respiratory effort closely."
Correct Answer: B) "Do not offer any kind of diversions to the patient."
Rationale: Patients with GBS are often cognitively intact but physically paralyzed and
potentially intubated. This leads to high levels of anxiety and sensory deprivation.
Diversional activities (music, television, reading) are essential for psychological well-being.
Communication methods, frequent repositioning, and pain management are all standard
and correct aspects of GBS care.
Question 7
Which clinical feature is a hallmark sign of a cholinergic crisis in a patient with Myasthenia
Gravis (MG)?
A) Severe dry mouth and constipation
B) Tachycardia and hypertension
C) Excessive bronchial secretions and miosis
D) Extreme muscle rigidity and high fever
E) Improved muscle strength after resting
Correct Answer: C) Excessive secretions
Rationale: A cholinergic crisis is caused by an overabundance of acetylcholine, usually due
to an overdose of anticholinesterase medication. This results in "SLUDGE" symptoms:
Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress, and Emesis.
Excessive secretions and bradycardia are critical signs that differentiate it from a
myasthenic crisis.
Question 8
Which of the following describes the underlying cause of a cholinergic crisis?
A) An acute lack of acetylcholine at the synaptic cleft.
B) A rapid infection of the cerebrospinal fluid.
C) A sudden withdrawal from corticosteroid therapy.
, 4
D) Excessive intake of anticholinesterase medication.
E) A secondary reaction to a viral immunization.
Correct Answer: D) It is caused by an excessive intake of anticholinesterase medication.
Rationale: When a patient takes too much anticholinesterase medication (like
pyridostigmine), the acetylcholine remains at the junction too long, causing a "depolarizing
block" of the muscle. This leads to weakness that can mimic the disease itself, but is
accompanied by parasympathetic over-stimulation (secretions, diarrhea, bradycardia).
Question 9
Which of the following are clinical features associated with a Myasthenic Crisis?
A) Bradycardia and excessive sweating
B) Tachycardia, pale/cool skin, and flaccid muscles
C) Pinpoint pupils and diarrhea
D) Increased salivation and muscle twitching
E) Hypertension and warm, flushed skin
Correct Answer: B) Tachycardia, pale/cool skin, and flaccid muscles
Rationale: A myasthenic crisis is caused by "not enough" medication or an exacerbation of
the disease (often triggered by infection). The patient experiences severe muscle weakness
and respiratory distress. The body compensates for the stress with a sympathetic response,
leading to tachycardia and cool skin. In contrast, bradycardia and secretions are seen in a
cholinergic crisis.
Question 10
Which diagnostic test is used to rapidly distinguish between a myasthenic crisis and a cholinergic
crisis?
A) Repetitive nerve stimulation (RNS)
B) Tensilon (Edrophonium) test
C) Chest CT scan to look for a thymoma
D) Lumbar puncture for protein analysis
E) Serum acetylcholine receptor antibody titer
Correct Answer: B) Tensilon test
Rationale: The Tensilon test involves injecting edrophonium, a short-acting
acetylcholinesterase inhibitor. If the patient's strength improves significantly, they are in a
myasthenic crisis (not enough ACh). If their strength worsens or they develop more
secretions/twitching, they are likely in a cholinergic crisis (too much ACh). Atropine must
be available at the bedside during this test to reverse potential cholinergic effects.
Question 11
The nurse is caring for a patient with Amyotrophic Lateral Sclerosis (ALS). Which complication
