NSG 4100 (AHIII) EXAM 4 TESTBANK NEWEST ACTUAL
EXAM STUDY THIS ONE QUESTIONS WITH 100%
VERIFIED ANSWERS.
The nurse is caring for a pt who is postoperative following a craniotomy. When writing the plan of care,
the nurse identifies a diagnosis of deficient fluid volume r/t fluid restriction & osmotic diuretic use. What
would be an appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - CORRECT ANSWERS-B
A pt who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the
adverse of effects of this medication, the nurse should prioritize which of the following in the pt's plan of
care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - CORRECT ANSWERS-C
A nurse is admitting a pt w a severe migraine headache and a hx of acute coronary syndrome. What
migraine medication would the nurse question for this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - CORRECT ANSWERS-C
The nurse is caring for a pt w increased ICP. The pt has a nursing dx of ineffective cerebral tissue
perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
,c. pays attention to grooming
d. obeys commands w appropriate motor responses - CORRECT ANSWERS-D
A pt exhibiting an altered LOC due to blunt-force trauma to the head is admitted to the ED. The physician
determines the pt's injury is causing increased ICP. The nurse should gauge the pt's LOC on the results of
what diagnostic tool?
a. Monro-Kellie hypothesis
b. Glasgow Coma Scale
c. Cranial nerve function
d. mental status examination - CORRECT ANSWERS-B
A pt w increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment
reveals that the pt is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in
suspecting the presence of what complication?
a. encephalitis
b. CSF leak
c. meningitis
d. catheter occlusion - CORRECT ANSWERS-C
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is contraindicated in
this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - CORRECT ANSWERS-B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care plan should
specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
c. projectile vomiting
,d. loss of corneal reflex - CORRECT ANSWERS-A
The neurologic ICU nurse is admitting a pt following a craniotomy using the supratentorial approach.
How should the nurse best position the pt?
a. position the pt supine
b. maintain HOB elevated at 30-45 degrees
c. position pt in prone position
d. maintain bed in Trendelenberg position - CORRECT ANSWERS-B
A pt has developed diabetes insipidness after having increased ICP following head trauma. What nursing
assessment best addresses this complication?
a. vigilant monitoring of fluid balance
b. continuous BP monitoring
c. serial arterial blood gases (ABGs)
d. monitoring of the pt's airway for patency - CORRECT ANSWERS-A
What would the nurse suspect when hourly assessment of UO on a pt postcrainiotomy exhibits a urine
output from a catheter of 1,500mL for 2 consecutive hours?
a. ruching syndrom
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - CORRECT ANSWERS-D
During the exam of an unconscious pt, the nurse observes that the pt's pupils are fixed and dilated. What
is the most plausible clinical significant of the nurses finding?
a. it suggests onset of metabolic problems
b. it indicates paralysis on the right side of the body
c. it indicates paralysis of cranial nerve X
d. it indicates an injury at the midbrain level - CORRECT ANSWERS-D
, Following a traumatic brain injury, a pt has been in a coma for several days. Which of the following
statements is true of this pt's current LOC?
a. the pt occasionally makes incomprehensible sounds
b. the pt's current LOC will likely become a permanent state
c. the pt may occasionally make non purposeful movements
d. the pt is incapable of spontaneous respirations - CORRECT ANSWERS-C
The nurse is caring for a pt w permanent neurologic impairments resulting from a traumatic head injury.
When working w this pt and family, what mutual goal should be prioritized?
a. achieve as high a level of function as possible
b. enhance the quantity of the pt's life
c. teach the family proper care of the pt
d. provide community assistance - CORRECT ANSWERS-A
The nurse is caring for a pt whose recent health hx includes an altered LOC. What should be the nurses
first action when assessing this pt?
a. assessing the pt's verbal response
b. assessing the pt's ability to follow complex commands
c. assessing the pt's judgment
d. assessing the pt's response to pain - CORRECT ANSWERS-A
The nurse for a pt in a persistent vegetative state is regularly assessing for potential complications.
Complications of neurologic dysfunction for which the nurse should assess include which of the
following? Select all that apply:
a. contractures
b. hemorrhage
c. pressure ulcers
d. venous thromboembolism
e. pneumonia - CORRECT ANSWERS-A, C, D, E
EXAM STUDY THIS ONE QUESTIONS WITH 100%
VERIFIED ANSWERS.
The nurse is caring for a pt who is postoperative following a craniotomy. When writing the plan of care,
the nurse identifies a diagnosis of deficient fluid volume r/t fluid restriction & osmotic diuretic use. What
would be an appropriate intervention for this diagnosis?
a. change the pt's position as indicated
b. monitor serum electrolytes
c. maintain NPO status
d. monitor arterial blood gas (ABG) values - CORRECT ANSWERS-B
A pt who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the
adverse of effects of this medication, the nurse should prioritize which of the following in the pt's plan of
care?
a. monitoring of pulse oximetry
b. administration of a low-protein diet
c. administration of thorough oral hygiene
d. fluid restriction as ordered - CORRECT ANSWERS-C
A nurse is admitting a pt w a severe migraine headache and a hx of acute coronary syndrome. What
migraine medication would the nurse question for this pt?
a. Rizatriptan (Mazalt)
b. naratriptan (Amerge)
c. sumatriptan succinate (Imitrex)
d. zomitriptan (Zomig) - CORRECT ANSWERS-C
The nurse is caring for a pt w increased ICP. The pt has a nursing dx of ineffective cerebral tissue
perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
a. copes w sensory deprivation
b. registers nml body temperature
,c. pays attention to grooming
d. obeys commands w appropriate motor responses - CORRECT ANSWERS-D
A pt exhibiting an altered LOC due to blunt-force trauma to the head is admitted to the ED. The physician
determines the pt's injury is causing increased ICP. The nurse should gauge the pt's LOC on the results of
what diagnostic tool?
a. Monro-Kellie hypothesis
b. Glasgow Coma Scale
c. Cranial nerve function
d. mental status examination - CORRECT ANSWERS-B
A pt w increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment
reveals that the pt is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in
suspecting the presence of what complication?
a. encephalitis
b. CSF leak
c. meningitis
d. catheter occlusion - CORRECT ANSWERS-C
The nurse is participating in the care of a pt w increased ICP. What diagnostic test is contraindicated in
this pt's treatment?
a. computed tomography (CT) scan
b. lumbar puncture
c. magnetic resonance imaging (MRI)
d. venous doppler studies - CORRECT ANSWERS-B
The nurse has created a plan of care for a pt who is at risk for increased ICP. The pt's care plan should
specify monitoring for what early sign of increased ICP?
a. disorientation and restlessness
b. decreased pulse and respirations
c. projectile vomiting
,d. loss of corneal reflex - CORRECT ANSWERS-A
The neurologic ICU nurse is admitting a pt following a craniotomy using the supratentorial approach.
How should the nurse best position the pt?
a. position the pt supine
b. maintain HOB elevated at 30-45 degrees
c. position pt in prone position
d. maintain bed in Trendelenberg position - CORRECT ANSWERS-B
A pt has developed diabetes insipidness after having increased ICP following head trauma. What nursing
assessment best addresses this complication?
a. vigilant monitoring of fluid balance
b. continuous BP monitoring
c. serial arterial blood gases (ABGs)
d. monitoring of the pt's airway for patency - CORRECT ANSWERS-A
What would the nurse suspect when hourly assessment of UO on a pt postcrainiotomy exhibits a urine
output from a catheter of 1,500mL for 2 consecutive hours?
a. ruching syndrom
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - CORRECT ANSWERS-D
During the exam of an unconscious pt, the nurse observes that the pt's pupils are fixed and dilated. What
is the most plausible clinical significant of the nurses finding?
a. it suggests onset of metabolic problems
b. it indicates paralysis on the right side of the body
c. it indicates paralysis of cranial nerve X
d. it indicates an injury at the midbrain level - CORRECT ANSWERS-D
, Following a traumatic brain injury, a pt has been in a coma for several days. Which of the following
statements is true of this pt's current LOC?
a. the pt occasionally makes incomprehensible sounds
b. the pt's current LOC will likely become a permanent state
c. the pt may occasionally make non purposeful movements
d. the pt is incapable of spontaneous respirations - CORRECT ANSWERS-C
The nurse is caring for a pt w permanent neurologic impairments resulting from a traumatic head injury.
When working w this pt and family, what mutual goal should be prioritized?
a. achieve as high a level of function as possible
b. enhance the quantity of the pt's life
c. teach the family proper care of the pt
d. provide community assistance - CORRECT ANSWERS-A
The nurse is caring for a pt whose recent health hx includes an altered LOC. What should be the nurses
first action when assessing this pt?
a. assessing the pt's verbal response
b. assessing the pt's ability to follow complex commands
c. assessing the pt's judgment
d. assessing the pt's response to pain - CORRECT ANSWERS-A
The nurse for a pt in a persistent vegetative state is regularly assessing for potential complications.
Complications of neurologic dysfunction for which the nurse should assess include which of the
following? Select all that apply:
a. contractures
b. hemorrhage
c. pressure ulcers
d. venous thromboembolism
e. pneumonia - CORRECT ANSWERS-A, C, D, E
