NR341/NR 341 Exam 3 V2 | Complex Adult
Health Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a patient who has just returned from the postanesthesia care unit
(PACU) following a craniotomy for a brain tumor. Which assessment finding should the nurse
report to the healthcare provider immediately?
A. A Glasgow Coma Scale (GCS) score that has decreased from 14 to 12
B. A blood pressure of 148/88 mmHg
C. Small amount of serosanguinous drainage on the dressing
D. The patient is sleepy but easily aroused by verbal stimuli
Correct Answer: A
Expert Explanation: A decrease in the Glasgow Coma Scale score is a significant indicator
of increasing intracranial pressure or neurological deterioration and must be reported
immediately. The nurse must prioritize monitoring for changes in level of consciousness as
it is often the earliest sign of brain injury. Timely intervention is critical to prevent
permanent damage or brain herniation.
,2. A client with a T4 spinal cord injury (SCI) reports a sudden, severe headache and blurred
vision. The nurse notes the client’s blood pressure is 200/110 mmHg and they are sweating
profusely above the level of injury. What is the nurse’s priority action?
A. Notify the healthcare provider immediately
B. Check the client for a full bladder or fecal impaction
C. Elevate the head of the bed to 45 degrees or higher
D. Administer an antihypertensive medication as ordered
Correct Answer: C
Expert Explanation: The client is exhibiting classic symptoms of autonomic dysreflexia,
which is a medical emergency in SCI patients. The first priority is to elevate the head of the
bed to a high-Fowler’s position to help lower the blood pressure through orthostatic
changes. After positioning, the nurse should then identify and alleviate the noxious
stimulus, such as an overdistended bladder.
3. A patient is diagnosed with Acute Kidney Injury (AKI) and is in the oliguric phase. Which
electrolyte abnormality is most likely to be observed by the nurse?
A. Hypophosphatemia
B. Hypokalemia
C. Hypercalcemia
D. Hyperkalemia
,Correct Answer: D
Expert Explanation: During the oliguric phase of AKI, the kidneys are unable to effectively
excrete potassium, leading to elevated serum levels. Hyperkalemia is a life-threatening
condition because it can lead to lethal cardiac arrhythmias. The nurse must monitor the
ECG for tall, peaked T-waves and other signs of cardiac instability.
4. A client in the Intensive Care Unit has a sustained intracranial pressure (ICP) of 22 mmHg.
Which of the following nursing interventions is appropriate to help manage the ICP?
A. Encourage the client to perform isometric exercises to maintain muscle tone
B. Perform frequent suctioning to ensure a clear airway
C. Maintain the head and neck in a neutral, midline position
D. Cluster nursing activities to allow for longer rest periods
Correct Answer: C
Expert Explanation: Maintaining a neutral, midline position of the head and neck prevents
venous obstruction and promotes drainage from the cerebral vault, which helps to lower
ICP. Frequent suctioning should be avoided because it can significantly increase
intracranial pressure. Nursing care should be spaced out rather than clustered to prevent
sustained elevations in ICP during activity.
5. The nurse is assessing a patient with a suspected basilar skull fracture. Which clinical
finding would support this diagnosis?
A. Nystagmus and vertigo
, B. Periorbital ecchymosis and Battle’s sign
C. Hyperreflexia and spasticity
D. Bilateral pupil dilation and non-reactivity
Correct Answer: B
Expert Explanation: Periorbital ecchymosis (raccoon eyes) and Battle’s sign
(postauricular ecchymosis) are classic indicators of a basilar skull fracture. These signs
result from blood tracking into the soft tissue following a fracture of the cranial base. The
nurse should also monitor for CSF leakage from the ears or nose, which further confirms
the diagnosis.
6. A client with Chronic Kidney Disease (CKD) is prescribed Erythropoietin (Epogen). The nurse
knows that the primary goal of this medication is to:
A. Lower serum potassium levels
B. Increase the production of red blood cells to treat anemia
C. Reduce phosphorus absorption in the gut
D. Improve the glomerular filtration rate
Correct Answer: B
Expert Explanation: Erythropoietin is a hormone normally produced by the kidneys that
stimulates the bone marrow to produce red blood cells. In CKD, the kidneys fail to produce
enough of this hormone, leading to chronic anemia. By administering Epogen, the nurse
Health Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a patient who has just returned from the postanesthesia care unit
(PACU) following a craniotomy for a brain tumor. Which assessment finding should the nurse
report to the healthcare provider immediately?
A. A Glasgow Coma Scale (GCS) score that has decreased from 14 to 12
B. A blood pressure of 148/88 mmHg
C. Small amount of serosanguinous drainage on the dressing
D. The patient is sleepy but easily aroused by verbal stimuli
Correct Answer: A
Expert Explanation: A decrease in the Glasgow Coma Scale score is a significant indicator
of increasing intracranial pressure or neurological deterioration and must be reported
immediately. The nurse must prioritize monitoring for changes in level of consciousness as
it is often the earliest sign of brain injury. Timely intervention is critical to prevent
permanent damage or brain herniation.
,2. A client with a T4 spinal cord injury (SCI) reports a sudden, severe headache and blurred
vision. The nurse notes the client’s blood pressure is 200/110 mmHg and they are sweating
profusely above the level of injury. What is the nurse’s priority action?
A. Notify the healthcare provider immediately
B. Check the client for a full bladder or fecal impaction
C. Elevate the head of the bed to 45 degrees or higher
D. Administer an antihypertensive medication as ordered
Correct Answer: C
Expert Explanation: The client is exhibiting classic symptoms of autonomic dysreflexia,
which is a medical emergency in SCI patients. The first priority is to elevate the head of the
bed to a high-Fowler’s position to help lower the blood pressure through orthostatic
changes. After positioning, the nurse should then identify and alleviate the noxious
stimulus, such as an overdistended bladder.
3. A patient is diagnosed with Acute Kidney Injury (AKI) and is in the oliguric phase. Which
electrolyte abnormality is most likely to be observed by the nurse?
A. Hypophosphatemia
B. Hypokalemia
C. Hypercalcemia
D. Hyperkalemia
,Correct Answer: D
Expert Explanation: During the oliguric phase of AKI, the kidneys are unable to effectively
excrete potassium, leading to elevated serum levels. Hyperkalemia is a life-threatening
condition because it can lead to lethal cardiac arrhythmias. The nurse must monitor the
ECG for tall, peaked T-waves and other signs of cardiac instability.
4. A client in the Intensive Care Unit has a sustained intracranial pressure (ICP) of 22 mmHg.
Which of the following nursing interventions is appropriate to help manage the ICP?
A. Encourage the client to perform isometric exercises to maintain muscle tone
B. Perform frequent suctioning to ensure a clear airway
C. Maintain the head and neck in a neutral, midline position
D. Cluster nursing activities to allow for longer rest periods
Correct Answer: C
Expert Explanation: Maintaining a neutral, midline position of the head and neck prevents
venous obstruction and promotes drainage from the cerebral vault, which helps to lower
ICP. Frequent suctioning should be avoided because it can significantly increase
intracranial pressure. Nursing care should be spaced out rather than clustered to prevent
sustained elevations in ICP during activity.
5. The nurse is assessing a patient with a suspected basilar skull fracture. Which clinical
finding would support this diagnosis?
A. Nystagmus and vertigo
, B. Periorbital ecchymosis and Battle’s sign
C. Hyperreflexia and spasticity
D. Bilateral pupil dilation and non-reactivity
Correct Answer: B
Expert Explanation: Periorbital ecchymosis (raccoon eyes) and Battle’s sign
(postauricular ecchymosis) are classic indicators of a basilar skull fracture. These signs
result from blood tracking into the soft tissue following a fracture of the cranial base. The
nurse should also monitor for CSF leakage from the ears or nose, which further confirms
the diagnosis.
6. A client with Chronic Kidney Disease (CKD) is prescribed Erythropoietin (Epogen). The nurse
knows that the primary goal of this medication is to:
A. Lower serum potassium levels
B. Increase the production of red blood cells to treat anemia
C. Reduce phosphorus absorption in the gut
D. Improve the glomerular filtration rate
Correct Answer: B
Expert Explanation: Erythropoietin is a hormone normally produced by the kidneys that
stimulates the bone marrow to produce red blood cells. In CKD, the kidneys fail to produce
enough of this hormone, leading to chronic anemia. By administering Epogen, the nurse
