NSG 4100 Nursing Practice: Adult Health Exam
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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 - Answer-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
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d. The client w multiple sclerosis who has scanning
speech - Answer-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
c. Omitting doses of medication
d. Intake of fatty foods - Answer-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) - Answer-C
The nurse is caring for a pt who is postoperative following
a craniotomy. When writing the plan of care, the nurse
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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 - Answer-B
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 - Answer-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:
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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 - Answer-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 -
Answer-C
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