NURS 102: EXAM TEST Q & A WITH EXPLANATIONS
A nurse is assessing a client who has meningitis and notes when passively flexing the
client's neck there is an involuntary flexion of both legs. Which of the following
conditions is the client displaying?
Correct. Brudzinski's sign.
Explanation. This client is manifesting a positive Brudzinski's sign, which is indicated when the
hips and knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of
meningitis.
Nuchal rigidity.
A client who displays nuchal rigidity has a stiff painful neck when the head is flexed.
Brudzinski's sign.
This client is manifesting a positive Brudzinski's sign, which is indicated when the hips and
knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.
Bradykinesia, which is slow or no movement of extremities, is a manifestation of Parkinson's
disease.
A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F),
and is prescribed a hypothermia blanket. While using this therapy, the nurse should
know that the client must carefully be observed for which of the following complications?
Correct. Shivering.
Explanation. The hypothermia blanket, if used improperly (at inappropriately low
temperatures, or without skin protection), can cause the client to cool too fast, leading to
shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in
an attempt to reduce heat loss. The body will also try to increase heat production by shivering,
,NURS 102: EXAM TEST Q & A WITH EXPLANATIONS
which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen
consumption.
A nurse is teaching a female client who has a new prescription for transdermal
sumatriptan to treat migraine headaches. Which of the following instructions should the
nurse include?
Correct. "Use contraception while taking this medication."
Explanation. Sumatriptan can cause teratogenesis and should not be used during pregnancy.
1…A nurse is reviewing the medical history of a client who is scheduled for a magnetic
resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces
of information in the client’s history is a contraindication to this procedure?
Correct answer: The client has a pacemaker.
Explanation: An MRI uses strong magnets and radio waves that are evaluated using computer
technology to view 3-dimensional images of the body. Since an MRI is magnetically generated,
it is not indicated for use in the presence of certain medical implants. Clients who have cerebral
aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because
the strong magnetic force can interfere with these devices and obscure surrounding anatomical
structures.
2….A nurse responds to a call from an assistive personnel that a client just had a seizure and is
unconscious. Which of the following assessments is the nurse’s priority?
Correct answer: Check airway patency.
Explanation: The nurse should apply the ABC priority-setting framework, which emphasizes the
basic core of human functioning: having an open airway, being able to breathe in adequate
amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in
any of these areas can indicate a threat to life and is the nurse’s priority concern. When
applying the ABC priority-setting framework, airway is always the highest priority because the
airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority
, NURS 102: EXAM TEST Q & A WITH EXPLANATIONS
because adequate ventilatory effort is essential in order for oxygen exchange to occur.
Circulation is the third-highest priority because the delivery of oxygen to critical organs only
occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The
priority assessment the nurse should make is to check the client's airway patency. The nurse
should establish and maintain the client’s airway to prevent respiratory arrest and hypoxia.
3….A nurse is caring for a client who has a brainstem injury. Which of the following
physiological functions should the nurse monitor?
Correct answer: Respiratory effort.
Explanation: The nurse should monitor the respiratory effort of a client who has an injury to the
brainstem. The medulla in the brainstem controls the respiratory center.
A nurse is assessing a client who has meningitis and notes when passively flexing the
client's neck there is an involuntary flexion of both legs. Which of the following
conditions is the client displaying?
Correct. Brudzinski's sign.
Explanation. This client is manifesting a positive Brudzinski's sign, which is indicated when the
hips and knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of
meningitis.
Nuchal rigidity.
A client who displays nuchal rigidity has a stiff painful neck when the head is flexed.
Brudzinski's sign.
This client is manifesting a positive Brudzinski's sign, which is indicated when the hips and
knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.
Bradykinesia, which is slow or no movement of extremities, is a manifestation of Parkinson's
disease.
A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F),
and is prescribed a hypothermia blanket. While using this therapy, the nurse should
know that the client must carefully be observed for which of the following complications?
Correct. Shivering.
Explanation. The hypothermia blanket, if used improperly (at inappropriately low
temperatures, or without skin protection), can cause the client to cool too fast, leading to
shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in
an attempt to reduce heat loss. The body will also try to increase heat production by shivering,
,NURS 102: EXAM TEST Q & A WITH EXPLANATIONS
which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen
consumption.
A nurse is teaching a female client who has a new prescription for transdermal
sumatriptan to treat migraine headaches. Which of the following instructions should the
nurse include?
Correct. "Use contraception while taking this medication."
Explanation. Sumatriptan can cause teratogenesis and should not be used during pregnancy.
1…A nurse is reviewing the medical history of a client who is scheduled for a magnetic
resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces
of information in the client’s history is a contraindication to this procedure?
Correct answer: The client has a pacemaker.
Explanation: An MRI uses strong magnets and radio waves that are evaluated using computer
technology to view 3-dimensional images of the body. Since an MRI is magnetically generated,
it is not indicated for use in the presence of certain medical implants. Clients who have cerebral
aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because
the strong magnetic force can interfere with these devices and obscure surrounding anatomical
structures.
2….A nurse responds to a call from an assistive personnel that a client just had a seizure and is
unconscious. Which of the following assessments is the nurse’s priority?
Correct answer: Check airway patency.
Explanation: The nurse should apply the ABC priority-setting framework, which emphasizes the
basic core of human functioning: having an open airway, being able to breathe in adequate
amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in
any of these areas can indicate a threat to life and is the nurse’s priority concern. When
applying the ABC priority-setting framework, airway is always the highest priority because the
airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority
, NURS 102: EXAM TEST Q & A WITH EXPLANATIONS
because adequate ventilatory effort is essential in order for oxygen exchange to occur.
Circulation is the third-highest priority because the delivery of oxygen to critical organs only
occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The
priority assessment the nurse should make is to check the client's airway patency. The nurse
should establish and maintain the client’s airway to prevent respiratory arrest and hypoxia.
3….A nurse is caring for a client who has a brainstem injury. Which of the following
physiological functions should the nurse monitor?
Correct answer: Respiratory effort.
Explanation: The nurse should monitor the respiratory effort of a client who has an injury to the
brainstem. The medulla in the brainstem controls the respiratory center.
