NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
NEWEST 2025/2026 WITH COMPLETE 200 QUESTIONS AND
CORRECT ANSWERS |ALREADY GRADED A+||BRAND NEW
VERSION!
A pt with a spinal cord injury at the T1 level complains of a severe HA and an
"anxious feeling." Which is the most appropriate initial reaction by the nurse?
A. try to calm the pt and make the environment soothing
B. assess for a full bladder
C. notify the healthcare provider
D. prepare the pt for diagnostic radiography - ANSWER-B. assess for a full bladder
Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or
higher, and is a life-threatening situation that will require immediate intervention
or the patient will die. The most common cause is an overextended bladder or
bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia,
visual changes, anxiety, and nausea. A calm, soothing environment is fine, though
not what the patient needs in this case. The nurse should recognize this as an
emergency and proceed accordingly. Once the assessment has been completed,
the findings will need to be communicated to the healthcare provider.
A hospitalized pt with a C7 cord injury begins to yell "I can't feel my legs
anymore." Which is the most appropriate action by the nurse?
A. remind the pt of her injury and try to comfort her
B. call the healthcare provider and get an order for radiologic evaluation
C. prepare the pt for surgery, as her condition is worsening
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, NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
D. explain to the pt that this could be a common, temporary problem - ANSWER-
D. explain to the pt that this could be a common, temporary problem
Rationale: Spinal shock is a condition almost half the people with acute spinal
injury experience. It is characterized by a temporary loss of reflex function below
level of injury, and includes the following symptomatology: flaccid paralysis of
skeletal muscles, loss of sensation below the injury, and possibly bowel and
bladder dysfunction and loss of ability to perspire below the injury level. In this
case, the nurse should explain to the patient what is happening.
The nurse is caring for a pt with increased ICP. The nurse realizes that some
nursing actions are contraindicated with increased ICP. Which nursing action
should be avoided?
A. reposition the pt every 2 hrs
B. position the pt with the head elevated 30 degrees
C. suction the airway every 2 hrs per standing orders
D. provide continuous oxygen as ordered - ANSWER-C. suction the airway every 2
hrs per standing orders
Rationale: Suctioning further increases intracranial pressure; therefore, suctioning
should be done to maintain a patent airway but not as a matter of routine.
Maintaining patient comfort by frequent repositioning as well as keeping the head
elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient
properly oxygenated may also help to control ICP.
2|Page
, NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
A pt with a spinal cord injury is admitted to the unit and placed in traction. Which
of the following actions is the nurse responsible for when caring for this pt? Select
all that apply.
A. modifying the traction weights as needed
B. assessing the pt's skin integrity
C. applying the traction upon admission
D. administering pain meds
E. providing passive ROM - ANSWER-B, D, E
Rationale: The healthcare provider is responsible for initial applying of the traction
device. The weights on the traction device must not be changed without the order
of a healthcare provider. When caring for a patient in traction, the nurse is
responsible for assessment and care of the skin due to the increased risk of skin
breakdown. The patient in traction is likely to experience pain and the nurse is
responsible for assessing this pain and administering the appropriate analgesic as
ordered. Passive range of motion helps prevent contractures; this is often
performed by a physical therapist or a nurse.
A pt has manifestations of autonomic dysreflexia. Which of these assessments
would indicate a possible cause for this condition? Select all that apply.
A. hypertension
B. kinked catheter tubing
C. respiratory wheezes and stridor
D. diarrhea
E. fecal impaction - ANSWER-B, E
3|Page
, NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing
allowing the bladder to become full, triggering massive vasoconstriction below
the injury site, producing the manifestations of this process. Acute symptoms of
autonomic dysreflexia, including a sustained elevated blood pressure, may
indicate fecal impaction. The other answers will not cause autonomic dysreflexia.
An unconscious pt receiving emergency care following an automobile crash
accident has a possible spinal cord injury. What guidelines for emergency care will
be followed? Select all that apply.
A. immobilize the neck using rolled towels of a cervical collar
B. the pt with be place in a supine position
C. the pt will be placed on a ventilator
D. the HOB will be elevated
E. the pt's head will be secured with a belt or tape secured to the stretcher -
ANSWER-A, B, E
Rationale: In the emergency setting, all patients who have sustained a trauma to
the head or spine, or are unconscious should be treated as though they have a
spinal cord injury. Immobilizing the neck, maintaining a supine position and
securing the patient's head to prevent movement are all basic guidelines of
emergency care. Placement on the ventilator and raising the head of the bed will
be considered after admittance to the hospital.
A pt with a spinal cord injury is recovering from spinal shock. The nurse realizes
that the pt should not develop a full bladder because what emergency condition
can occur if it is not corrected quickly?
A. autonomic dysreflexia
4|Page
NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
NEWEST 2025/2026 WITH COMPLETE 200 QUESTIONS AND
CORRECT ANSWERS |ALREADY GRADED A+||BRAND NEW
VERSION!
A pt with a spinal cord injury at the T1 level complains of a severe HA and an
"anxious feeling." Which is the most appropriate initial reaction by the nurse?
A. try to calm the pt and make the environment soothing
B. assess for a full bladder
C. notify the healthcare provider
D. prepare the pt for diagnostic radiography - ANSWER-B. assess for a full bladder
Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or
higher, and is a life-threatening situation that will require immediate intervention
or the patient will die. The most common cause is an overextended bladder or
bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia,
visual changes, anxiety, and nausea. A calm, soothing environment is fine, though
not what the patient needs in this case. The nurse should recognize this as an
emergency and proceed accordingly. Once the assessment has been completed,
the findings will need to be communicated to the healthcare provider.
A hospitalized pt with a C7 cord injury begins to yell "I can't feel my legs
anymore." Which is the most appropriate action by the nurse?
A. remind the pt of her injury and try to comfort her
B. call the healthcare provider and get an order for radiologic evaluation
C. prepare the pt for surgery, as her condition is worsening
1|Page
, NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
D. explain to the pt that this could be a common, temporary problem - ANSWER-
D. explain to the pt that this could be a common, temporary problem
Rationale: Spinal shock is a condition almost half the people with acute spinal
injury experience. It is characterized by a temporary loss of reflex function below
level of injury, and includes the following symptomatology: flaccid paralysis of
skeletal muscles, loss of sensation below the injury, and possibly bowel and
bladder dysfunction and loss of ability to perspire below the injury level. In this
case, the nurse should explain to the patient what is happening.
The nurse is caring for a pt with increased ICP. The nurse realizes that some
nursing actions are contraindicated with increased ICP. Which nursing action
should be avoided?
A. reposition the pt every 2 hrs
B. position the pt with the head elevated 30 degrees
C. suction the airway every 2 hrs per standing orders
D. provide continuous oxygen as ordered - ANSWER-C. suction the airway every 2
hrs per standing orders
Rationale: Suctioning further increases intracranial pressure; therefore, suctioning
should be done to maintain a patent airway but not as a matter of routine.
Maintaining patient comfort by frequent repositioning as well as keeping the head
elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient
properly oxygenated may also help to control ICP.
2|Page
, NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
A pt with a spinal cord injury is admitted to the unit and placed in traction. Which
of the following actions is the nurse responsible for when caring for this pt? Select
all that apply.
A. modifying the traction weights as needed
B. assessing the pt's skin integrity
C. applying the traction upon admission
D. administering pain meds
E. providing passive ROM - ANSWER-B, D, E
Rationale: The healthcare provider is responsible for initial applying of the traction
device. The weights on the traction device must not be changed without the order
of a healthcare provider. When caring for a patient in traction, the nurse is
responsible for assessment and care of the skin due to the increased risk of skin
breakdown. The patient in traction is likely to experience pain and the nurse is
responsible for assessing this pain and administering the appropriate analgesic as
ordered. Passive range of motion helps prevent contractures; this is often
performed by a physical therapist or a nurse.
A pt has manifestations of autonomic dysreflexia. Which of these assessments
would indicate a possible cause for this condition? Select all that apply.
A. hypertension
B. kinked catheter tubing
C. respiratory wheezes and stridor
D. diarrhea
E. fecal impaction - ANSWER-B, E
3|Page
, NSG 460 FINAL EXAM / NSG 460 FINAL EXAM ACTUAL EXAM
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing
allowing the bladder to become full, triggering massive vasoconstriction below
the injury site, producing the manifestations of this process. Acute symptoms of
autonomic dysreflexia, including a sustained elevated blood pressure, may
indicate fecal impaction. The other answers will not cause autonomic dysreflexia.
An unconscious pt receiving emergency care following an automobile crash
accident has a possible spinal cord injury. What guidelines for emergency care will
be followed? Select all that apply.
A. immobilize the neck using rolled towels of a cervical collar
B. the pt with be place in a supine position
C. the pt will be placed on a ventilator
D. the HOB will be elevated
E. the pt's head will be secured with a belt or tape secured to the stretcher -
ANSWER-A, B, E
Rationale: In the emergency setting, all patients who have sustained a trauma to
the head or spine, or are unconscious should be treated as though they have a
spinal cord injury. Immobilizing the neck, maintaining a supine position and
securing the patient's head to prevent movement are all basic guidelines of
emergency care. Placement on the ventilator and raising the head of the bed will
be considered after admittance to the hospital.
A pt with a spinal cord injury is recovering from spinal shock. The nurse realizes
that the pt should not develop a full bladder because what emergency condition
can occur if it is not corrected quickly?
A. autonomic dysreflexia
4|Page
