NSG 4100 (AHIII) Comprehensive Predictor Verified
Multiple Choice and Conceptual Actual Exam Questions
With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
1. An ED nurse has just received a call from EMS that they are transporting a
17 y/o man who has just sustained a spinal cord injury (SCI). The nurse
recognizes that the most common cause of this type of injury is what?
a. sports-related injuries
b. acts of violence
c. injuries due to a fall
d. motor vehicle accidents - ANSWER D
2. A pt w spinal cord injury has a nursing dx of altered mobility & the nurse
recognizes the increased risk for DVT. Which of the following would be
included as an appropriate nursing intervention to prevent a DVT from
occurring?
a. pacing the pt on a fluid restriction as ordered
b. applying thigh-high elastic stockings
c. administering an antifibriolyic agent
d. assisting the pt w passive ROM exercises - ANSWER B
3. Paramedics have brought an intubated pt to the ED following a head injury
due to acceleration-deceleration MVA. Increased ICP is suspected.
Appropriate nursing interventions would include which of the following?
a. keep HOB flat at all times
b. teach pt to perform the Valsalva maneuver
c. administer benzodiazepines on a PRN basis
d. perform endotracheal suctioning every hour - ANSWER C
,4. A pt who suffered a spinal cord injury is experiencing an exaggerated
autonomic response. What aspect of the pt's current health status is most
likely to have precipitated this event?
a. the pt received a blood transfusion
b. the pt's analgesia regimen was recently changed
c. the pt was not repositioned during the night shift
d. the pt's urinary catheter became occluded - ANSWER D
5. A pt is admitted to the neurologic ICU w a spinal cord injury. In writing the
pt's care plan, the nurse specifies that contractures can be best prevented
by what action?
a. reposting pt q2hr
b. initiating ROM as soon as the pt initiates
c. initiating ROM exercises as soon as possible after injury
d. perfuming ROM exercises one a day - ANSWER C
6. A pt w a head injury had been increasingly agitated & the nurse has
consequently identifies a risk for injury. What is the nurses best intervention
for preventing injury?
a. restrain the pt as ordered
b. administer opioids PRN as ordered
c. arrange for friends & family members to sit w the pt
d. pad the side rails of the pt's bed - ANSWER D
7. A pt w a C5 spinal cord injury is tetraplegic. After being moved out of the
ICU, the pt c/o sever throbbing HA. What should the nurse do first?
a. check the pt's indwelling urinary catheter for kinks to ensure patecny
b. lower the HOB to improve perfusion
, c. administer analgesia
d. reassure the pt that headaches are expected after spinal cord injuries
- ANSWER A
8. A pt is admitted to the neurologic ICU w a spinal cord injury. When
assessing the pt the nurse notes there is a sudden depression fo reflex
activity in the spinal cord below the level of injury. What should the nurse
suspect?
a. epidural hemorrhage
b. hypertensive emergency
c. spinal shock
d. hypovolemia - ANSWER C
9. An elderly woman found w a head injury on the floor of her home is
subsequently admitted to the neurologic ICU. What is the best rationale for
the following physician orders: elevate the HOB; keep the head in neutral
alignment w no neck flexion or head rotation; avoid sharp hip flexion?
a. to decrease cerebral arterial pressure
b. to avoid impeding venous outflow
c. to prevent flexion contractures
d. to prevent aspiration of stomach contents - ANSWER B
10.A pt w a T12 is in spinal shock. The nurse will expect to observe what
assessment finding?
a. absence of reflexes along w flaccid extremities
b. positive Babinskis reflex along w spastic extremities
c. hyperreflexia along w spastic extremities
d. spasticity of all 4 extremities - ANSWER A
, 11.A nurse is reviewing the trend of a pt's scores on the Glasgow Coma Scale
(GCS). This allows the nurse to gauge what aspect of the pt's status?
a. reflex activity
b. level of consciousness
c. cognitive ability
d. sensory involvement - ANSWER B
12.The nurse is caring for a pt who is rapidly progressing toward brain death.
The nurse should be aware of what cardinal signs of brain death? Select all
that apply.
a. absence of pain response
b. apnea
c. coma
d. absence of brain stem reflexes
e. absence of deep tendon reflexes - ANSWER B, C, D
13.Following a SCI a pt is placed in halo traction. While performing pin site
care, the nurse notes that one of the traction pins has become detached.
The nurse would be correct in implementing what priority nursing action?
a. compete the pin site care to decrease risk of infection
b. notify the neurosurgeon of the occurrence
c. stabilize the head in a lateral position
d. reattach the pin to prevent further head trauma - ANSWER B
14.The ED is notifies that a 6 y/o is in transit w a suspected brain injury after
being struck by a car. The child is unresponsive at this time, but vital signs
are within acceptable limits. What will be the primary goal of initial
therapy?
a. promote adequate circulation
b. treating the child's increased ICP
Multiple Choice and Conceptual Actual Exam Questions
With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
1. An ED nurse has just received a call from EMS that they are transporting a
17 y/o man who has just sustained a spinal cord injury (SCI). The nurse
recognizes that the most common cause of this type of injury is what?
a. sports-related injuries
b. acts of violence
c. injuries due to a fall
d. motor vehicle accidents - ANSWER D
2. A pt w spinal cord injury has a nursing dx of altered mobility & the nurse
recognizes the increased risk for DVT. Which of the following would be
included as an appropriate nursing intervention to prevent a DVT from
occurring?
a. pacing the pt on a fluid restriction as ordered
b. applying thigh-high elastic stockings
c. administering an antifibriolyic agent
d. assisting the pt w passive ROM exercises - ANSWER B
3. Paramedics have brought an intubated pt to the ED following a head injury
due to acceleration-deceleration MVA. Increased ICP is suspected.
Appropriate nursing interventions would include which of the following?
a. keep HOB flat at all times
b. teach pt to perform the Valsalva maneuver
c. administer benzodiazepines on a PRN basis
d. perform endotracheal suctioning every hour - ANSWER C
,4. A pt who suffered a spinal cord injury is experiencing an exaggerated
autonomic response. What aspect of the pt's current health status is most
likely to have precipitated this event?
a. the pt received a blood transfusion
b. the pt's analgesia regimen was recently changed
c. the pt was not repositioned during the night shift
d. the pt's urinary catheter became occluded - ANSWER D
5. A pt is admitted to the neurologic ICU w a spinal cord injury. In writing the
pt's care plan, the nurse specifies that contractures can be best prevented
by what action?
a. reposting pt q2hr
b. initiating ROM as soon as the pt initiates
c. initiating ROM exercises as soon as possible after injury
d. perfuming ROM exercises one a day - ANSWER C
6. A pt w a head injury had been increasingly agitated & the nurse has
consequently identifies a risk for injury. What is the nurses best intervention
for preventing injury?
a. restrain the pt as ordered
b. administer opioids PRN as ordered
c. arrange for friends & family members to sit w the pt
d. pad the side rails of the pt's bed - ANSWER D
7. A pt w a C5 spinal cord injury is tetraplegic. After being moved out of the
ICU, the pt c/o sever throbbing HA. What should the nurse do first?
a. check the pt's indwelling urinary catheter for kinks to ensure patecny
b. lower the HOB to improve perfusion
, c. administer analgesia
d. reassure the pt that headaches are expected after spinal cord injuries
- ANSWER A
8. A pt is admitted to the neurologic ICU w a spinal cord injury. When
assessing the pt the nurse notes there is a sudden depression fo reflex
activity in the spinal cord below the level of injury. What should the nurse
suspect?
a. epidural hemorrhage
b. hypertensive emergency
c. spinal shock
d. hypovolemia - ANSWER C
9. An elderly woman found w a head injury on the floor of her home is
subsequently admitted to the neurologic ICU. What is the best rationale for
the following physician orders: elevate the HOB; keep the head in neutral
alignment w no neck flexion or head rotation; avoid sharp hip flexion?
a. to decrease cerebral arterial pressure
b. to avoid impeding venous outflow
c. to prevent flexion contractures
d. to prevent aspiration of stomach contents - ANSWER B
10.A pt w a T12 is in spinal shock. The nurse will expect to observe what
assessment finding?
a. absence of reflexes along w flaccid extremities
b. positive Babinskis reflex along w spastic extremities
c. hyperreflexia along w spastic extremities
d. spasticity of all 4 extremities - ANSWER A
, 11.A nurse is reviewing the trend of a pt's scores on the Glasgow Coma Scale
(GCS). This allows the nurse to gauge what aspect of the pt's status?
a. reflex activity
b. level of consciousness
c. cognitive ability
d. sensory involvement - ANSWER B
12.The nurse is caring for a pt who is rapidly progressing toward brain death.
The nurse should be aware of what cardinal signs of brain death? Select all
that apply.
a. absence of pain response
b. apnea
c. coma
d. absence of brain stem reflexes
e. absence of deep tendon reflexes - ANSWER B, C, D
13.Following a SCI a pt is placed in halo traction. While performing pin site
care, the nurse notes that one of the traction pins has become detached.
The nurse would be correct in implementing what priority nursing action?
a. compete the pin site care to decrease risk of infection
b. notify the neurosurgeon of the occurrence
c. stabilize the head in a lateral position
d. reattach the pin to prevent further head trauma - ANSWER B
14.The ED is notifies that a 6 y/o is in transit w a suspected brain injury after
being struck by a car. The child is unresponsive at this time, but vital signs
are within acceptable limits. What will be the primary goal of initial
therapy?
a. promote adequate circulation
b. treating the child's increased ICP
