NSG 4100 (AHIII) Exam 4 (ACTUAL 2025/2026)Q
p p p p p p p
UESTIONS AND VERIFIED ANSWERS. p p p
The pt w fibromyalgia is suffering from pain at 12 of the 18 ident
p p p p p p p p p p p p p
ification sites, including the neck & upper back & knees.The pt a
p p p p p p p p p p p p
lso reports non-
p p
refreshing sleep, depression, & being anxious when dealing w
p p p p p p p p p
multiple tasks. The nurse should teach this pt about what treatm
p p p p p p p p p p
ents? Select all that apply:
p p p p
a. Minimal aerobic exercise p p
b. Relaxation strategy (biofeedback) p p
c. Anti-seizure during phenytoin p p
d. Serotonin reuptake inhibitor (e.g. sertraline) p p p p
e. Establish a regular sleep pattern p p p p p
B, D, E
p p
A pt w a head injury had been increasingly agitated & the nurse h
p p p p p p p p p p p p p
as consequently identifies a risk for injury. What is thenurses be
p p p p p p p p p p p
st intervention for preventing injury?
p p p p
a. restrain the pt as ordered p p p p
b. administer opioids PRN as ordered p p p p
c. arrange for friends & family members to sit w the pt
p p p p p p p p p p
d. pad the side rails of the pt's bedD
p p p p p p p p
,A pt w a C5 spinal cord injury is tetraplegic. After being move
p p p p p p p p p p p p
d out of the ICU, the pt c/o sever throbbing HA. Whatshould t
p p p p p p p p p p p p p
he nurse do first?
p p p
a. check the pt's indwelling urinary catheter for kinks toe
p p p p p p p p p
nsure patecny p
b. lower the HOB to improve perfusion p p p p p
c. administer analgesia p
d. reassure the pt that headaches are expected after spinal cordin
p p p p p p p p p p
juries
A
A pt is admitted to the neurologic ICU w a spinal cord injury.Wh
p p p p p p p p p p p p p
en assessing the pt the nurse notes there is a sudden depression f
p p p p p p p p p p p p
o reflex activity in the spinal cord below the levelof injury. What
p p p p p p p p p p p p
should the nurse suspect?
p p p p
a. epidural hemorrhage p
b. hypertensive emergency p
c. spinal shock p
d. hypovolemia p
C
,An elderly woman found w a head injury on the floor of her hom
p p p p p p p p p p p p p
e is subsequently admitted to the neurologic ICU. What isthe bes
p p p p p p p p p p p
t rationale for the following physician orders: elevate the HOB; k
p p p p p p p p p p
eep the head in neutral alignment w no neck flexion or head rotati
p p p p p p p p p p p p
on; avoid sharp hip flexion?
p p p p
a. to decrease cerebral arterial pressure
p p p p
b. to avoid impeding venous outflow
p p p p
c. to prevent flexion contractures
p p p
d. to prevent aspiration of stomach contents
p p p p p p
B
A pt w a T12 is in spinal shock. The nurse will expect toobs
p p p p p p p p p p p p p p
erve what assessment finding?
p p p
a. absence of reflexes along w flaccid extremities p p p p p p
b. positive Babinskis reflex along w spastic extremitiesp p p p p p
c. hyperreflexia along w spastic extremities p p p p
d. spasticity of all 4 extremities p p p p p
A
A nurse is reviewing the trend of a pt's scores on the GlasgowCo
p p p p p p p p p p p p p
ma Scale (GCS). This allows the nurse to gauge what aspect of t
p p p p p p p p p p p p
he pt's status?
p p
a. reflex activity p
, b. level of consciousness
p p
c. cognitive ability p
d. sensory involvement p p
B
The nurse is caring for a pt who is rapidly progressing towardbra
p p p p p p p p p p p p
in death. The nurse should be aware of what cardinal signsof bra
p p p p p p p p p p p p
in death? Select all that apply.
p p p p p
a. absence of pain response p p p
b. apnea
c. coma
d. absence of brain stem reflexes p p p p
e. absence of deep tendon reflexes p p p p p
B, C, D
p p
Following a SCI a pt is placed in halo traction. While perf
p p p p p p p p p p p
orming pin site care, the nurse notes that one of thetractio
p p p p p p p p p p p
n pins has become detached. The nurse would becorrect i
p p p p p p p p p p
n implementing what priority nursing action?
p p p p p
a. compete the pin site care to decrease risk of infection
p p p p p p p p p
b. notify the neurosurgeon of the occurrence
p p p p p
c. stabilize the head in a lateral position
p p p p p p
p p p p p p p
UESTIONS AND VERIFIED ANSWERS. p p p
The pt w fibromyalgia is suffering from pain at 12 of the 18 ident
p p p p p p p p p p p p p
ification sites, including the neck & upper back & knees.The pt a
p p p p p p p p p p p p
lso reports non-
p p
refreshing sleep, depression, & being anxious when dealing w
p p p p p p p p p
multiple tasks. The nurse should teach this pt about what treatm
p p p p p p p p p p
ents? Select all that apply:
p p p p
a. Minimal aerobic exercise p p
b. Relaxation strategy (biofeedback) p p
c. Anti-seizure during phenytoin p p
d. Serotonin reuptake inhibitor (e.g. sertraline) p p p p
e. Establish a regular sleep pattern p p p p p
B, D, E
p p
A pt w a head injury had been increasingly agitated & the nurse h
p p p p p p p p p p p p p
as consequently identifies a risk for injury. What is thenurses be
p p p p p p p p p p p
st intervention for preventing injury?
p p p p
a. restrain the pt as ordered p p p p
b. administer opioids PRN as ordered p p p p
c. arrange for friends & family members to sit w the pt
p p p p p p p p p p
d. pad the side rails of the pt's bedD
p p p p p p p p
,A pt w a C5 spinal cord injury is tetraplegic. After being move
p p p p p p p p p p p p
d out of the ICU, the pt c/o sever throbbing HA. Whatshould t
p p p p p p p p p p p p p
he nurse do first?
p p p
a. check the pt's indwelling urinary catheter for kinks toe
p p p p p p p p p
nsure patecny p
b. lower the HOB to improve perfusion p p p p p
c. administer analgesia p
d. reassure the pt that headaches are expected after spinal cordin
p p p p p p p p p p
juries
A
A pt is admitted to the neurologic ICU w a spinal cord injury.Wh
p p p p p p p p p p p p p
en assessing the pt the nurse notes there is a sudden depression f
p p p p p p p p p p p p
o reflex activity in the spinal cord below the levelof injury. What
p p p p p p p p p p p p
should the nurse suspect?
p p p p
a. epidural hemorrhage p
b. hypertensive emergency p
c. spinal shock p
d. hypovolemia p
C
,An elderly woman found w a head injury on the floor of her hom
p p p p p p p p p p p p p
e is subsequently admitted to the neurologic ICU. What isthe bes
p p p p p p p p p p p
t rationale for the following physician orders: elevate the HOB; k
p p p p p p p p p p
eep the head in neutral alignment w no neck flexion or head rotati
p p p p p p p p p p p p
on; avoid sharp hip flexion?
p p p p
a. to decrease cerebral arterial pressure
p p p p
b. to avoid impeding venous outflow
p p p p
c. to prevent flexion contractures
p p p
d. to prevent aspiration of stomach contents
p p p p p p
B
A pt w a T12 is in spinal shock. The nurse will expect toobs
p p p p p p p p p p p p p p
erve what assessment finding?
p p p
a. absence of reflexes along w flaccid extremities p p p p p p
b. positive Babinskis reflex along w spastic extremitiesp p p p p p
c. hyperreflexia along w spastic extremities p p p p
d. spasticity of all 4 extremities p p p p p
A
A nurse is reviewing the trend of a pt's scores on the GlasgowCo
p p p p p p p p p p p p p
ma Scale (GCS). This allows the nurse to gauge what aspect of t
p p p p p p p p p p p p
he pt's status?
p p
a. reflex activity p
, b. level of consciousness
p p
c. cognitive ability p
d. sensory involvement p p
B
The nurse is caring for a pt who is rapidly progressing towardbra
p p p p p p p p p p p p
in death. The nurse should be aware of what cardinal signsof bra
p p p p p p p p p p p p
in death? Select all that apply.
p p p p p
a. absence of pain response p p p
b. apnea
c. coma
d. absence of brain stem reflexes p p p p
e. absence of deep tendon reflexes p p p p p
B, C, D
p p
Following a SCI a pt is placed in halo traction. While perf
p p p p p p p p p p p
orming pin site care, the nurse notes that one of thetractio
p p p p p p p p p p p
n pins has become detached. The nurse would becorrect i
p p p p p p p p p p
n implementing what priority nursing action?
p p p p p
a. compete the pin site care to decrease risk of infection
p p p p p p p p p
b. notify the neurosurgeon of the occurrence
p p p p p
c. stabilize the head in a lateral position
p p p p p p
