NSG 4100 Exam 4 Final Actual Updated 2026 With Detailed Answers
,
,Question 1:
The nurse is caring for a client with a traumatic brain injury. Which finding
requires immediate follow-up?
A) Urine output of 100 mL over 4 hours
B) Urine output of 300 mL in 1 hour
C) Urine output of 50 mL per hour
D) Urine output of 1500 mL in 24 hours
Answer: B) Urine output of 300 mL in 1 hour
Rationale: A urine output of 300 mL in one hour (300 mL/hr) is excessive and
may indicate diabetes insipidus, a complication of traumatic brain injury due to
decreased ADH. This requires immediate intervention. Normal urine output is
30-50 mL/hr.
Question 2:
The nurse is caring for a client with a traumatic brain injury that occurred 12
hours ago. The client was unconscious for one hour. The nurse should notify
the provider immediately for which finding?
A) Pupil size 3 mm bilaterally
B) Pupil size increasing from 4 mm to 7 mm
C) Pupil size 4 mm bilaterally
D) Pupil size reacting sluggishly
Answer: B) Pupil size increasing from 4 mm to 7 mm
Rationale: A sudden increase in pupil size (dilation) indicates increasing
intracranial pressure (ICP) and possible herniation. This is a neurological
emergency requiring immediate intervention. Peak ICP often occurs 24-72
hours after injury, but changes at 12 hours are significant.
, Question 3:
The nurse is caring for a client with a closed head injury who is on a
mechanical ventilator and at risk for increased intracranial pressure. Which
nursing intervention is most appropriate?
A) Keep the head of the bed flat
B) Elevate the head of the bed 30-45 degrees
C) Place the client in Trendelenburg position
D) Turn the client every 4 hours
Answer: B) Elevate the head of the bed 30-45 degrees
Rationale: Elevating the head of the bed 30-45 degrees promotes venous
drainage from the brain, reducing intracranial pressure. Flat positioning (A)
increases ICP. Trendelenburg (C) would dangerously increase ICP. Turning (D)
should be done carefully to avoid increasing ICP.
Question 4:
A client with a spinal cord injury is wearing a halo vest. The family reports that
they can fit two fingers between the vest and the client's skin. What should the
nurse do?
A) Tighten the vest immediately
B) Loosen the vest to prevent skin breakdown
C) Document this as a normal finding
D) Notify the provider for readjustment
Answer: C) Document this as a normal finding
Rationale: Two fingers should fit between the halo vest and the client's skin to
allow for breathing and prevent skin breakdown. This is the correct fit.
Tightening (A) would restrict breathing. Loosening (B) would compromise
immobilization. The provider does not need notification for a normal finding.
,
,Question 1:
The nurse is caring for a client with a traumatic brain injury. Which finding
requires immediate follow-up?
A) Urine output of 100 mL over 4 hours
B) Urine output of 300 mL in 1 hour
C) Urine output of 50 mL per hour
D) Urine output of 1500 mL in 24 hours
Answer: B) Urine output of 300 mL in 1 hour
Rationale: A urine output of 300 mL in one hour (300 mL/hr) is excessive and
may indicate diabetes insipidus, a complication of traumatic brain injury due to
decreased ADH. This requires immediate intervention. Normal urine output is
30-50 mL/hr.
Question 2:
The nurse is caring for a client with a traumatic brain injury that occurred 12
hours ago. The client was unconscious for one hour. The nurse should notify
the provider immediately for which finding?
A) Pupil size 3 mm bilaterally
B) Pupil size increasing from 4 mm to 7 mm
C) Pupil size 4 mm bilaterally
D) Pupil size reacting sluggishly
Answer: B) Pupil size increasing from 4 mm to 7 mm
Rationale: A sudden increase in pupil size (dilation) indicates increasing
intracranial pressure (ICP) and possible herniation. This is a neurological
emergency requiring immediate intervention. Peak ICP often occurs 24-72
hours after injury, but changes at 12 hours are significant.
, Question 3:
The nurse is caring for a client with a closed head injury who is on a
mechanical ventilator and at risk for increased intracranial pressure. Which
nursing intervention is most appropriate?
A) Keep the head of the bed flat
B) Elevate the head of the bed 30-45 degrees
C) Place the client in Trendelenburg position
D) Turn the client every 4 hours
Answer: B) Elevate the head of the bed 30-45 degrees
Rationale: Elevating the head of the bed 30-45 degrees promotes venous
drainage from the brain, reducing intracranial pressure. Flat positioning (A)
increases ICP. Trendelenburg (C) would dangerously increase ICP. Turning (D)
should be done carefully to avoid increasing ICP.
Question 4:
A client with a spinal cord injury is wearing a halo vest. The family reports that
they can fit two fingers between the vest and the client's skin. What should the
nurse do?
A) Tighten the vest immediately
B) Loosen the vest to prevent skin breakdown
C) Document this as a normal finding
D) Notify the provider for readjustment
Answer: C) Document this as a normal finding
Rationale: Two fingers should fit between the halo vest and the client's skin to
allow for breathing and prevent skin breakdown. This is the correct fit.
Tightening (A) would restrict breathing. Loosening (B) would compromise
immobilization. The provider does not need notification for a normal finding.
