NSG 4100 (AHIII) Exam 4 (ACTUAL 2025/2026) Q
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UESTIONS AND VERIFIED ANSWERS. m m m
The pt w fibromyalgia is suffering from pain at 12 of the 18 id
m m m m m m m m m m m m m
entification sites, including the neck & upper back & knees. Th
m m m m m m m m m m
e pt also reports non-
m m m m
refreshing sleep, depression, & being anxious when dealing w
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multiple tasks. The nurse should teach this pt about what treat
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ments? Select all that apply:
m m m m
a. Minimal aerobic exercise m m
b. Relaxation strategy (biofeedback) m m
c. Anti-seizure during phenytoin m m
d. Serotonin reuptake inhibitor (e.g. sertraline)
m m m m
e. Establish a regular sleep pattern m m m m m
B, D, E
m m
A pt w a head injury had been increasingly agitated & the nurs
m m m m m m m m m m m m
e has consequently identifies a risk for injury. What is the nurs
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es best intervention for preventing injury?
m m m m m
a. restrain the pt as ordered m m m m
b. administer opioids PRN as ordered m m m m
c. arrange for friends & family members to sit w the pt
m m m m m m m m m m
d. pad the side rails of the pt's bed
m m m m m m m m
D
,A pt w a C5 spinal cord injury is tetraplegic. After being move
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d out of the ICU, the pt c/o sever throbbing HA. What should t
m m m m m m m m m m m m m
he nurse do first?
m m m
a. check the pt's indwelling urinary catheter for kinks to
m m m m m m m m m
ensure patecny m
b. lower the HOB to improve perfusion m m m m m
c. administer analgesia m
d. reassure the pt that headaches are expected after spinal cord
m m m m m m m m m m
injuries
A
A pt is admitted to the neurologic ICU w a spinal cord injury.
m m m m m m m m m m m m m
When assessing the pt the nurse notes there is a sudden depress
m m m m m m m m m m m
ion fo reflex activity in the spinal cord below the level of injury
m m m m m m m m m m m m
. What should the nurse suspect?
m m m m m
a. epidural hemorrhage m
b. hypertensive emergency m
c. spinal shock m
d. hypovolemia
C
m
,An elderly woman found w a head injury on the floor of her ho
m m m m m m m m m m m m m
me is subsequently admitted to the neurologic ICU. What is th
m m m m m m m m m m
e best rationale for the following physician orders: elevate the
m m m m m m m m m m
HOB; keep the head in neutral alignment w no neck flexion or
m m m m m m m m m m m m
head rotation; avoid sharp hip flexion?
m m m m m
a. to decrease cerebral arterial pressure
m m m m
b. to avoid impeding venous outflow
m m m m
c. to prevent flexion contractures
m m m
d. to prevent aspiration of stomach contents
m m m m m m
B
A pt w a T12 is in spinal shock. The nurse will expect to observ
m m m m m m m m m m m m m m
e what assessment finding?
m m m
a. absence of reflexes along w flaccid extremities
m m m m m m
b. positive Babinskis reflex along w spastic extremities
m m m m m m
c. hyperreflexia along w spastic extremities m m m m
d. spasticity of all 4 extremities m m m m m
A
A nurse is reviewing the trend of a pt's scores on the Glasgow
m m m m m m m m m m m m m
Coma Scale (GCS). This allows the nurse to gauge what aspect
m m m m m m m m m m
of the pt's status?
m m m m
a. reflex activity m
, b. level of consciousness
m m
c. cognitive ability m
d. sensory involvement m
B
m
The nurse is caring for a pt who is rapidly progressing toward
m m m m m m m m m m m m
brain death. The nurse should be aware of what cardinal signs
m m m m m m m m m m m
of brain death? Select all that apply.
m m m m m m
a. absence of pain response m m m
b. apnea
c. coma
d. absence of brain stem reflexes m m m m
e. absence of deep tendon reflexes
m m m m m
B, C, D
m m
Following a SCI a pt is placed in halo traction. While perform
m m m m m m m m m m m
ing pin site care, the nurse notes that one of the traction pins h
m m m m m m m m m m m m m
as become detached. The nurse would be correct in implement
m m m m m m m m m
ing what priority nursing action?
m m m m
a. compete the pin site care to decrease risk of infection
m m m m m m m m m
b. notify the neurosurgeon of the occurrence
m m m m m
c. stabilize the head in a lateral position
m m m m m m
m m m m m m m
UESTIONS AND VERIFIED ANSWERS. m m m
The pt w fibromyalgia is suffering from pain at 12 of the 18 id
m m m m m m m m m m m m m
entification sites, including the neck & upper back & knees. Th
m m m m m m m m m m
e pt also reports non-
m m m m
refreshing sleep, depression, & being anxious when dealing w
m m m m m m m m m
multiple tasks. The nurse should teach this pt about what treat
m m m m m m m m m m
ments? Select all that apply:
m m m m
a. Minimal aerobic exercise m m
b. Relaxation strategy (biofeedback) m m
c. Anti-seizure during phenytoin m m
d. Serotonin reuptake inhibitor (e.g. sertraline)
m m m m
e. Establish a regular sleep pattern m m m m m
B, D, E
m m
A pt w a head injury had been increasingly agitated & the nurs
m m m m m m m m m m m m
e has consequently identifies a risk for injury. What is the nurs
m m m m m m m m m m m
es best intervention for preventing injury?
m m m m m
a. restrain the pt as ordered m m m m
b. administer opioids PRN as ordered m m m m
c. arrange for friends & family members to sit w the pt
m m m m m m m m m m
d. pad the side rails of the pt's bed
m m m m m m m m
D
,A pt w a C5 spinal cord injury is tetraplegic. After being move
m m m m m m m m m m m m
d out of the ICU, the pt c/o sever throbbing HA. What should t
m m m m m m m m m m m m m
he nurse do first?
m m m
a. check the pt's indwelling urinary catheter for kinks to
m m m m m m m m m
ensure patecny m
b. lower the HOB to improve perfusion m m m m m
c. administer analgesia m
d. reassure the pt that headaches are expected after spinal cord
m m m m m m m m m m
injuries
A
A pt is admitted to the neurologic ICU w a spinal cord injury.
m m m m m m m m m m m m m
When assessing the pt the nurse notes there is a sudden depress
m m m m m m m m m m m
ion fo reflex activity in the spinal cord below the level of injury
m m m m m m m m m m m m
. What should the nurse suspect?
m m m m m
a. epidural hemorrhage m
b. hypertensive emergency m
c. spinal shock m
d. hypovolemia
C
m
,An elderly woman found w a head injury on the floor of her ho
m m m m m m m m m m m m m
me is subsequently admitted to the neurologic ICU. What is th
m m m m m m m m m m
e best rationale for the following physician orders: elevate the
m m m m m m m m m m
HOB; keep the head in neutral alignment w no neck flexion or
m m m m m m m m m m m m
head rotation; avoid sharp hip flexion?
m m m m m
a. to decrease cerebral arterial pressure
m m m m
b. to avoid impeding venous outflow
m m m m
c. to prevent flexion contractures
m m m
d. to prevent aspiration of stomach contents
m m m m m m
B
A pt w a T12 is in spinal shock. The nurse will expect to observ
m m m m m m m m m m m m m m
e what assessment finding?
m m m
a. absence of reflexes along w flaccid extremities
m m m m m m
b. positive Babinskis reflex along w spastic extremities
m m m m m m
c. hyperreflexia along w spastic extremities m m m m
d. spasticity of all 4 extremities m m m m m
A
A nurse is reviewing the trend of a pt's scores on the Glasgow
m m m m m m m m m m m m m
Coma Scale (GCS). This allows the nurse to gauge what aspect
m m m m m m m m m m
of the pt's status?
m m m m
a. reflex activity m
, b. level of consciousness
m m
c. cognitive ability m
d. sensory involvement m
B
m
The nurse is caring for a pt who is rapidly progressing toward
m m m m m m m m m m m m
brain death. The nurse should be aware of what cardinal signs
m m m m m m m m m m m
of brain death? Select all that apply.
m m m m m m
a. absence of pain response m m m
b. apnea
c. coma
d. absence of brain stem reflexes m m m m
e. absence of deep tendon reflexes
m m m m m
B, C, D
m m
Following a SCI a pt is placed in halo traction. While perform
m m m m m m m m m m m
ing pin site care, the nurse notes that one of the traction pins h
m m m m m m m m m m m m m
as become detached. The nurse would be correct in implement
m m m m m m m m m
ing what priority nursing action?
m m m m
a. compete the pin site care to decrease risk of infection
m m m m m m m m m
b. notify the neurosurgeon of the occurrence
m m m m m
c. stabilize the head in a lateral position
m m m m m m
