NSG 4100 (AHIII) Exam 4 Testbank Latest Update
2025-2026 Exam 185 Questions with 100%
Verified Correct Answers Guaranteed A+
A 69 y/o pt is brought to the ED bc a family member found him lying on the floor
disoriented and lethargic. The physician suspects bacterial meningitis & admits the pt to
the ICU. The nurse knows that risk factors for an unfavorable outcome include what?
Select all that apply:
a. BP greater than 140/90 mm Hg
b. HR greater than 120 bpm
c. older age
d. low Glasgow scale
e. lack of previous immunizations - CORRECT ANSWER: B, C, D
A client recovering from head injury is participating in care. The nurse determines that
the client understands measure to prevent elevations in ICP if the nurse observes the
client doing which of the following?
a. blowing the nose
b. isometric exercise
c. coughing vigorously
d. healing during repositioning - CORRECT ANSWER: D
A client w Guillain-Barre syndrome has ascending paralysis and is intubated and
receiving mechanical intubation. Which strategy should the nurse incorporate in the plan
of care to help the client cope w this illness?
a. giving the client full control over care decisions & restricting visitors
b. providing positive feedback and encouraging active ROM
c. providing info, giving positive feedback, & encouraging relaxation
,d, proving IV administered sedatives, reducing distractions, & limiting visitors -
CORRECT ANSWER: C
A client w SCI is prone to experience autonomic dysreflexia. The nurse should include
which measures in the plan of care to minimize the risk of occurrence? Select all that
apply:
a. keep the linen wrinkle-free under the client
b. preventing unnecessary pressure on the lower limbs
c. limiting bladder cauterization to once every 12 hrs
d. turning & repositioning the client every 2 hrs
e. ensuring that the client has a bowel movement - CORRECT ANSWER: A, B, D
A clinic nurse is providing patient education prior to a patients scheduled palliative
radiotherapy to her spine. At the completion of the patient teaching, the patient
continues to ask the same questions that the nurse has already addressed. What is the
plausible conclusion that the nurse should draw from this?
a. the pt is not listening effectively
b. the pt is noncompliant w the plan of care
c. the pt may have low intelligence quotient or a cognitive deficit
d. the pt has not achieved the desire learning outcomes - CORRECT ANSWER: D
A critical care nurse is aware of similarities and differences between the treatments for
different types of shock. Which of the following interventions is used in all types of
shock?
a. agressive hypoglycemic control
b. administration of hypertonic IV fluids
c. early provision of nutritional support
d. agressive antibiotic therapy - CORRECT ANSWER: C
,A critical care nurse is aware of the high incidence of ventilator-associated pneumonia
(VAP) in patients who are being treated for shock. What intervention should be specified
in the patients plan of care while the patient is ventilated?
a. performing frequent oral care
b. maintinas pt in supine position
c. suctioning pt q15mins unless contraindicated
d. administering prophylactic abx, as ordered - CORRECT ANSWER: A
A critical care nurse is planning assessments in the knowledge that patients in shock
are vulnerable to developing fluid replacement complications. For what signs and
symptoms should the nurse monitor the patient? Select all that apply.
a. hypovolemia
b. difficulty breathing
c. cardiovascular overload
d. pulmonary edema
e. hypoglycemia - CORRECT ANSWER: B, C, D
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 - CORRECT ANSWER: C
A home care nurse is performing a visit to a patients home to perform wound care
following the patients hospital treatment for severe burns. While interacting with the
patient, the nurse should assess for evidence of what complication?
A) Psychosis
B) Post-traumatic stress disorder
, C) Delirium
D) Vascular dementia - CORRECT ANSWER: B
A male pt presents to clinic c/o headache. The nurse notes that the pt is guarding his
neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the
pt may have meningitis. What is another well-recognized sign of this infection?
a. negative Brudzinskis sign
b. positive Kernigs sign
c. hyper patellar reflex
d. sluggish pupil reaction - CORRECT ANSWER: B
A neurologic flow chart is often used to document the care of a pt w a traumatic brain
injury. At what point in the pt's care should the nurse begin to use a neurologic flow
chart?
a. when the pt's condition begins to deteriorate
b. as soon as the initial assessment is made
c. at the beginning of each shift
d. when there is a clinically significant change in the pt's condition - CORRECT
ANSWER: B
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 - CORRECT ANSWER: C
A nurse has reported for a shift at a busy burns and plastics unit in a large university
hospital. Which patient is most likely to have life-threatening complications?
2025-2026 Exam 185 Questions with 100%
Verified Correct Answers Guaranteed A+
A 69 y/o pt is brought to the ED bc a family member found him lying on the floor
disoriented and lethargic. The physician suspects bacterial meningitis & admits the pt to
the ICU. The nurse knows that risk factors for an unfavorable outcome include what?
Select all that apply:
a. BP greater than 140/90 mm Hg
b. HR greater than 120 bpm
c. older age
d. low Glasgow scale
e. lack of previous immunizations - CORRECT ANSWER: B, C, D
A client recovering from head injury is participating in care. The nurse determines that
the client understands measure to prevent elevations in ICP if the nurse observes the
client doing which of the following?
a. blowing the nose
b. isometric exercise
c. coughing vigorously
d. healing during repositioning - CORRECT ANSWER: D
A client w Guillain-Barre syndrome has ascending paralysis and is intubated and
receiving mechanical intubation. Which strategy should the nurse incorporate in the plan
of care to help the client cope w this illness?
a. giving the client full control over care decisions & restricting visitors
b. providing positive feedback and encouraging active ROM
c. providing info, giving positive feedback, & encouraging relaxation
,d, proving IV administered sedatives, reducing distractions, & limiting visitors -
CORRECT ANSWER: C
A client w SCI is prone to experience autonomic dysreflexia. The nurse should include
which measures in the plan of care to minimize the risk of occurrence? Select all that
apply:
a. keep the linen wrinkle-free under the client
b. preventing unnecessary pressure on the lower limbs
c. limiting bladder cauterization to once every 12 hrs
d. turning & repositioning the client every 2 hrs
e. ensuring that the client has a bowel movement - CORRECT ANSWER: A, B, D
A clinic nurse is providing patient education prior to a patients scheduled palliative
radiotherapy to her spine. At the completion of the patient teaching, the patient
continues to ask the same questions that the nurse has already addressed. What is the
plausible conclusion that the nurse should draw from this?
a. the pt is not listening effectively
b. the pt is noncompliant w the plan of care
c. the pt may have low intelligence quotient or a cognitive deficit
d. the pt has not achieved the desire learning outcomes - CORRECT ANSWER: D
A critical care nurse is aware of similarities and differences between the treatments for
different types of shock. Which of the following interventions is used in all types of
shock?
a. agressive hypoglycemic control
b. administration of hypertonic IV fluids
c. early provision of nutritional support
d. agressive antibiotic therapy - CORRECT ANSWER: C
,A critical care nurse is aware of the high incidence of ventilator-associated pneumonia
(VAP) in patients who are being treated for shock. What intervention should be specified
in the patients plan of care while the patient is ventilated?
a. performing frequent oral care
b. maintinas pt in supine position
c. suctioning pt q15mins unless contraindicated
d. administering prophylactic abx, as ordered - CORRECT ANSWER: A
A critical care nurse is planning assessments in the knowledge that patients in shock
are vulnerable to developing fluid replacement complications. For what signs and
symptoms should the nurse monitor the patient? Select all that apply.
a. hypovolemia
b. difficulty breathing
c. cardiovascular overload
d. pulmonary edema
e. hypoglycemia - CORRECT ANSWER: B, C, D
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 - CORRECT ANSWER: C
A home care nurse is performing a visit to a patients home to perform wound care
following the patients hospital treatment for severe burns. While interacting with the
patient, the nurse should assess for evidence of what complication?
A) Psychosis
B) Post-traumatic stress disorder
, C) Delirium
D) Vascular dementia - CORRECT ANSWER: B
A male pt presents to clinic c/o headache. The nurse notes that the pt is guarding his
neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the
pt may have meningitis. What is another well-recognized sign of this infection?
a. negative Brudzinskis sign
b. positive Kernigs sign
c. hyper patellar reflex
d. sluggish pupil reaction - CORRECT ANSWER: B
A neurologic flow chart is often used to document the care of a pt w a traumatic brain
injury. At what point in the pt's care should the nurse begin to use a neurologic flow
chart?
a. when the pt's condition begins to deteriorate
b. as soon as the initial assessment is made
c. at the beginning of each shift
d. when there is a clinically significant change in the pt's condition - CORRECT
ANSWER: B
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 - CORRECT ANSWER: C
A nurse has reported for a shift at a busy burns and plastics unit in a large university
hospital. Which patient is most likely to have life-threatening complications?
