NSG 4100 EXAM 4 FINAL: NURSING
PRACTICE – ADULT HEALTH III, ACTUAL
QUESTIONS AND ANSWERS LATEST
UPDATE 2026/2027 (GRADED A+)- GALEN
COLLEGE OF NURSING
AT GALEN COLLEGE OF NURSING
NURSING PRACTICE – ADULT HEALTH III
______________________________________________________________________________
_______________
Neurological, Respiratory, SCI, and Burn Management
______________________________________________________________________________
_______________
Question 1: Head Trauma Output
A nurse is monitoring a client with a head injury. The client has a urine outpu
t of 300 mL/hr for the past 2 hours. What is the nurse’s priority action?
A. Document as normal finding
B. Restrict fluids
C. Notify the provider
D. Administer diuretics
Correct Answer: C. Notify the provider
Rationale:
A urine output of 300 mL/hr is excessive and may indicate diabetes insipidus,
a complication of head trauma caused by decreased ADH secretion. Early rec
ognition is critical to prevent severe dehydration and electrolyte imbalance.
This finding is abnormal and requires immediate provider notification.
Question 2: Traumatic Brain Injury Assessment
,Which assessment finding in a client with traumatic brain injury requires imm
ediate provider notification?
A. Pupils equal and reactive at 3 mm
B. Pupil dilation to 8 mm and nonreactive
C. Mild headache
D. Slight confusion
Correct Answer: B. Pupil dilation to 8 mm and nonreactive
Rationale:
Dilated, nonreactive pupils indicate increased intracranial pressure and possi
ble brain herniation. This is a neurological emergency requiring immediate in
tervention. The other findings may occur but are less critical.
Question 3: Mechanical Ventilation and ICP
What intervention helps reduce intracranial pressure in a mechanically ventil
ated client with a head injury?
A. Lay flat
B. Elevate HOB 30–45°
C. Turn frequently
D. Increase stimulation
Correct Answer: B. Elevate HOB 30–45°
Rationale:
Elevating the head promotes venous drainage from the brain and reduces IC
P. Lying flat increases ICP, and excessive stimulation can worsen neurologica
l status. Proper positioning is a key noninvasive intervention.
Question 4: Halo Vest Care
Which finding indicates proper halo vest application?
A. Vest is tightly secured with no space
B. Two fingers fit under vest
C. Loose pins
D. Skin redness under vest
,Correct Answer: B. Two fingers fit under vest
Rationale:
A properly fitted halo vest allows space for two fingers to ensure it is secure
but not too tight. Excessive tightness can cause skin breakdown, while loose
ness can compromise spinal alignment. Skin and pin care must be monitored
closely.
Question 5: Cerebral Hemorrhage
Which symptom indicates worsening intracranial pressure in a client with cer
ebral hemorrhage?
A. Drowsiness
B. Agitation
C. Mild nausea
D. Fatigue
Correct Answer: B. Agitation
Rationale:
Agitation is an early sign of increased ICP and neurological deterioration. It of
ten precedes more severe symptoms like decreased consciousness. Immedia
te evaluation is required.
Question 6: Guillain-Barré Syndrome
Which finding is expected in Guillain-Barré syndrome?
A. Intermittent coughing with secretions
B. Severe hypertension
C. Fixed pupils
D. Hyperreflexia
Correct Answer: A. Intermittent coughing with secretions
Rationale:
GBS affects peripheral nerves, leading to muscle weakness and impaired air
way clearance. Moderate secretions may be expected but require monitoring
. Hyperreflexia is not typical—hyporeflexia is more common.
, Question 7: ALS Care
Which statement by a client with ALS is appropriate?
A. “I expect to recover fully.”
B. “I want full resuscitation no matter what.”
C. “I would like to discuss DNR status.”
D. “This disease is temporary.”
Correct Answer: C. “I would like to discuss DNR status.”
Rationale:
ALS is progressive and terminal, so discussions about advanced directives ar
e appropriate. Respecting patient autonomy is essential. The other statemen
ts reflect misunderstanding of the disease.
Question 8: Post-Craniotomy Output
A client has 200 mL drainage after craniotomy. What should the nurse do?
A. Document as expected
B. Notify provider
C. Clamp drain
D. Increase fluids
Correct Answer: B. Notify provider
Rationale:
Excessive drainage may indicate hemorrhage or complications. Early interve
ntion is critical to prevent deterioration. This amount is above expected post
operative drainage.
Question 9: CSF Leak
What does post-nasal drip after craniotomy indicate?
A. Infection
B. Normal healing
PRACTICE – ADULT HEALTH III, ACTUAL
QUESTIONS AND ANSWERS LATEST
UPDATE 2026/2027 (GRADED A+)- GALEN
COLLEGE OF NURSING
AT GALEN COLLEGE OF NURSING
NURSING PRACTICE – ADULT HEALTH III
______________________________________________________________________________
_______________
Neurological, Respiratory, SCI, and Burn Management
______________________________________________________________________________
_______________
Question 1: Head Trauma Output
A nurse is monitoring a client with a head injury. The client has a urine outpu
t of 300 mL/hr for the past 2 hours. What is the nurse’s priority action?
A. Document as normal finding
B. Restrict fluids
C. Notify the provider
D. Administer diuretics
Correct Answer: C. Notify the provider
Rationale:
A urine output of 300 mL/hr is excessive and may indicate diabetes insipidus,
a complication of head trauma caused by decreased ADH secretion. Early rec
ognition is critical to prevent severe dehydration and electrolyte imbalance.
This finding is abnormal and requires immediate provider notification.
Question 2: Traumatic Brain Injury Assessment
,Which assessment finding in a client with traumatic brain injury requires imm
ediate provider notification?
A. Pupils equal and reactive at 3 mm
B. Pupil dilation to 8 mm and nonreactive
C. Mild headache
D. Slight confusion
Correct Answer: B. Pupil dilation to 8 mm and nonreactive
Rationale:
Dilated, nonreactive pupils indicate increased intracranial pressure and possi
ble brain herniation. This is a neurological emergency requiring immediate in
tervention. The other findings may occur but are less critical.
Question 3: Mechanical Ventilation and ICP
What intervention helps reduce intracranial pressure in a mechanically ventil
ated client with a head injury?
A. Lay flat
B. Elevate HOB 30–45°
C. Turn frequently
D. Increase stimulation
Correct Answer: B. Elevate HOB 30–45°
Rationale:
Elevating the head promotes venous drainage from the brain and reduces IC
P. Lying flat increases ICP, and excessive stimulation can worsen neurologica
l status. Proper positioning is a key noninvasive intervention.
Question 4: Halo Vest Care
Which finding indicates proper halo vest application?
A. Vest is tightly secured with no space
B. Two fingers fit under vest
C. Loose pins
D. Skin redness under vest
,Correct Answer: B. Two fingers fit under vest
Rationale:
A properly fitted halo vest allows space for two fingers to ensure it is secure
but not too tight. Excessive tightness can cause skin breakdown, while loose
ness can compromise spinal alignment. Skin and pin care must be monitored
closely.
Question 5: Cerebral Hemorrhage
Which symptom indicates worsening intracranial pressure in a client with cer
ebral hemorrhage?
A. Drowsiness
B. Agitation
C. Mild nausea
D. Fatigue
Correct Answer: B. Agitation
Rationale:
Agitation is an early sign of increased ICP and neurological deterioration. It of
ten precedes more severe symptoms like decreased consciousness. Immedia
te evaluation is required.
Question 6: Guillain-Barré Syndrome
Which finding is expected in Guillain-Barré syndrome?
A. Intermittent coughing with secretions
B. Severe hypertension
C. Fixed pupils
D. Hyperreflexia
Correct Answer: A. Intermittent coughing with secretions
Rationale:
GBS affects peripheral nerves, leading to muscle weakness and impaired air
way clearance. Moderate secretions may be expected but require monitoring
. Hyperreflexia is not typical—hyporeflexia is more common.
, Question 7: ALS Care
Which statement by a client with ALS is appropriate?
A. “I expect to recover fully.”
B. “I want full resuscitation no matter what.”
C. “I would like to discuss DNR status.”
D. “This disease is temporary.”
Correct Answer: C. “I would like to discuss DNR status.”
Rationale:
ALS is progressive and terminal, so discussions about advanced directives ar
e appropriate. Respecting patient autonomy is essential. The other statemen
ts reflect misunderstanding of the disease.
Question 8: Post-Craniotomy Output
A client has 200 mL drainage after craniotomy. What should the nurse do?
A. Document as expected
B. Notify provider
C. Clamp drain
D. Increase fluids
Correct Answer: B. Notify provider
Rationale:
Excessive drainage may indicate hemorrhage or complications. Early interve
ntion is critical to prevent deterioration. This amount is above expected post
operative drainage.
Question 9: CSF Leak
What does post-nasal drip after craniotomy indicate?
A. Infection
B. Normal healing
