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
SECTION 1: Neurological Trauma & Critical Care
______________________________________________________________________________
_______________
Question 1
A nurse is monitoring a client with head trauma. Which finding requires imme
diate follow-up?
A. Urine output of 50 mL/hr
B. Urine output of 300 mL/hr
C. Blood pressure of 120/80 mmHg
D. Heart rate of 88 bpm
Correct Answer: B
Rationale:
A urine output of 300 mL/hr may indicate diabetes insipidus, a complication o
f head trauma caused by decreased ADH secretion. This can lead to severe d
ehydration and electrolyte imbalance. Prompt intervention is necessary to pr
event further deterioration.
Question 2
A nurse is assessing a client with traumatic brain injury. Which finding should
be reported immediately?
,A. Pupils equal and reactive
B. Pupil size increasing to 7–10 mm
C. Glasgow Coma Scale of 14
D. Mild headache
Correct Answer: B
Rationale:
A sudden increase in pupil size indicates possible increased intracranial press
ure or brain herniation. This is a neurological emergency requiring immediate
provider notification. Early intervention can prevent irreversible brain damag
e.
Question 3
Which intervention is most appropriate for a client with a closed head injury
on mechanical ventilation?
A. Keep the client flat
B. Elevate HOB 30–45 degrees
C. Turn every hour
D. Restrict fluids
Correct Answer: B
Rationale:
Elevating the head of the bed promotes venous drainage from the brain, red
ucing intracranial pressure. Keeping the head flat can worsen ICP. This is a st
andard intervention in neurocritical care.
Question 4
A nurse is caring for a client with a halo vest. Which finding is expected?
A. No space between vest and skin
B. One finger space
C. Two-finger space
D. Loose vest movement
Correct Answer: C
,Rationale:
A properly fitted halo vest allows space for two fingers between the vest and
the body. This ensures stability without compromising circulation or causing
skin breakdown. Too tight or too loose can cause complications.
Question 5
A client with a cerebral hemorrhage becomes agitated. What is the nurse’s p
riority action?
A. Reassure the client
B. Administer pain medication
C. Notify the provider
D. Encourage rest
Correct Answer: C
Rationale:
Agitation is an early sign of increased intracranial pressure. This change in n
eurological status requires immediate evaluation. Delayed intervention can l
ead to rapid deterioration.
Question 6
Which finding is expected in a client with Guillain-Barré Syndrome?
A. Absent cough reflex
B. Intermittent coughing with secretions
C. Complete paralysis immediately
D. Hyperactive reflexes
Correct Answer: B
Rationale:
Intermittent coughing with moderate secretions is expected as respiratory m
uscles weaken gradually. However, worsening symptoms must be monitored
closely. Early detection of respiratory failure is critical.
Question 7
, A client with ALS states they do not want resuscitation. What is the appropria
te interpretation?
A. This is abnormal thinking
B. This is expected due to disease progression
C. The client is depressed
D. The family should decide
Correct Answer: B
Rationale:
ALS is a progressive, terminal illness, and patients often make end-of-life dec
isions early. Respecting autonomy is essential in nursing care. Advance direc
tives should be honored.
Question 8
A post-craniotomy client has a drainage output increase to 200 mL. What sho
uld the nurse do?
A. Document and continue monitoring
B. Increase fluids
C. Notify the nurse/provider
D. Reposition the client
Correct Answer: C
Rationale:
An increase in drainage may indicate bleeding or complications. Immediate r
eporting is necessary to prevent worsening neurological outcomes. Close mo
nitoring is essential post-craniotomy.
Question 9
A client reports post-nasal drip after a craniotomy. What is the priority concer
n?
A. Allergies
B. Sinus infection
C. CSF leak
D. Dehydration
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
SECTION 1: Neurological Trauma & Critical Care
______________________________________________________________________________
_______________
Question 1
A nurse is monitoring a client with head trauma. Which finding requires imme
diate follow-up?
A. Urine output of 50 mL/hr
B. Urine output of 300 mL/hr
C. Blood pressure of 120/80 mmHg
D. Heart rate of 88 bpm
Correct Answer: B
Rationale:
A urine output of 300 mL/hr may indicate diabetes insipidus, a complication o
f head trauma caused by decreased ADH secretion. This can lead to severe d
ehydration and electrolyte imbalance. Prompt intervention is necessary to pr
event further deterioration.
Question 2
A nurse is assessing a client with traumatic brain injury. Which finding should
be reported immediately?
,A. Pupils equal and reactive
B. Pupil size increasing to 7–10 mm
C. Glasgow Coma Scale of 14
D. Mild headache
Correct Answer: B
Rationale:
A sudden increase in pupil size indicates possible increased intracranial press
ure or brain herniation. This is a neurological emergency requiring immediate
provider notification. Early intervention can prevent irreversible brain damag
e.
Question 3
Which intervention is most appropriate for a client with a closed head injury
on mechanical ventilation?
A. Keep the client flat
B. Elevate HOB 30–45 degrees
C. Turn every hour
D. Restrict fluids
Correct Answer: B
Rationale:
Elevating the head of the bed promotes venous drainage from the brain, red
ucing intracranial pressure. Keeping the head flat can worsen ICP. This is a st
andard intervention in neurocritical care.
Question 4
A nurse is caring for a client with a halo vest. Which finding is expected?
A. No space between vest and skin
B. One finger space
C. Two-finger space
D. Loose vest movement
Correct Answer: C
,Rationale:
A properly fitted halo vest allows space for two fingers between the vest and
the body. This ensures stability without compromising circulation or causing
skin breakdown. Too tight or too loose can cause complications.
Question 5
A client with a cerebral hemorrhage becomes agitated. What is the nurse’s p
riority action?
A. Reassure the client
B. Administer pain medication
C. Notify the provider
D. Encourage rest
Correct Answer: C
Rationale:
Agitation is an early sign of increased intracranial pressure. This change in n
eurological status requires immediate evaluation. Delayed intervention can l
ead to rapid deterioration.
Question 6
Which finding is expected in a client with Guillain-Barré Syndrome?
A. Absent cough reflex
B. Intermittent coughing with secretions
C. Complete paralysis immediately
D. Hyperactive reflexes
Correct Answer: B
Rationale:
Intermittent coughing with moderate secretions is expected as respiratory m
uscles weaken gradually. However, worsening symptoms must be monitored
closely. Early detection of respiratory failure is critical.
Question 7
, A client with ALS states they do not want resuscitation. What is the appropria
te interpretation?
A. This is abnormal thinking
B. This is expected due to disease progression
C. The client is depressed
D. The family should decide
Correct Answer: B
Rationale:
ALS is a progressive, terminal illness, and patients often make end-of-life dec
isions early. Respecting autonomy is essential in nursing care. Advance direc
tives should be honored.
Question 8
A post-craniotomy client has a drainage output increase to 200 mL. What sho
uld the nurse do?
A. Document and continue monitoring
B. Increase fluids
C. Notify the nurse/provider
D. Reposition the client
Correct Answer: C
Rationale:
An increase in drainage may indicate bleeding or complications. Immediate r
eporting is necessary to prevent worsening neurological outcomes. Close mo
nitoring is essential post-craniotomy.
Question 9
A client reports post-nasal drip after a craniotomy. What is the priority concer
n?
A. Allergies
B. Sinus infection
C. CSF leak
D. Dehydration
