NSG 4100 (AHIII) EXAM TESTBANK 2026/2027 WITH ACTUAL
QUSTIONS AND 100% COREECT ANSWERS
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 Trendelenburg position - ANS... -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 - ANS... -A
What would the nurse suspect when hourly assessment of UO on a pt post
craniotomy exhibits a urine output from a catheter of 1,500mL for 2 consecutive
hours?
a. ruching syndrome
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - ANS... -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 - ANS... -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 - ANS... -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. achieves as high a level of function as possible
b. enhances the quantity of the pt's life
c. teaches the family proper care of the pt
d. provides community assistance - ANS... -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 - ANS... -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 - ANS... -A, C, D, E
The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to
be ordered to reduce the edema surrounding the tumor?
a. solumedrol
b. dextromethorphan
c. dexamethasone
d. furosemide - ANS... -C
The nurse is caring for a pt who sustained a moderate head injury following a
bicycle accident. The nurses most recent assessment reveals that the pt's respiratory
effort has increased. What is the nurses most appropriate response?
a. inform the care team and assess for further signs of possible increased ICP
b. administer bronchodilators and monitor the pt's LOC
c. increase the pt's bed height and reassess in 30 mins
d. administer a bolus of normal line as ordered - ANS... -A
,A pt has a poor prognosis after being involved in a motor vehicle accident resulting
in a head injury. As the pt's ICP increases and condition worsens, the nurse knows
to assess for indications of approaching death. These indications include which of
the following?
a. hemiplegia
b. dry mucous membranes
c. signs of internal bleeding
d. loss of brain stem reflexes - ANS... -D
When caring for a pt w increased ICP the nurse knows the importance of
monitoring for possible secondary complications, including syndrome of
inappropriate antidiuretic hormone (SIADH). What nursing interventions would
the nurse most likely initiate if the pt developed SIADH?
a. fluid restriction
b. transfusion of platelets
c. transfusion of fresh frozen plasma (FFP)
d. electrolyte restriction - ANS... -A
The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites,
including the neck & upper back & knees. The pt also reports non-refreshing sleep,
depression, & being anxious when dealing w multiple tasks. The nurse should
teach this pt about what treatments? Select all that apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern - ANS... -B, D, E
The nurse caring for a client w a head injury would recognize which assessment
finding as early signs of increased ICP? Select all that apply:
a. Kussmaul breathing
b. Projectile vomiting
c. Weakness in one extremity
d. Headache not aggravated by movement of straining
e. Decreased urine output
f. Papilledema - ANS... -A, C, D
A nurse caring for a client diagnosed to have head injury. Which of the following
situations needs intervention by the nurse?
, a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3 hours in the
evening
d. The head of bed is elevated at 30 degree angle - ANS... -C
The critical care nurse is caring for a client w a head injury secondary to a
motorcycle accident who, on morning rounds, is responsive to painful stimulus and
assumes decorticate posturing. Two hours later, which data would warrant
immediate intervention by the nurse?
a. The client has purposeful movement when the nurse rubs the sternum
b. The client extends the upper and lower extremities in response to painful stimuli
c. The client is aimlessly thrashing in the bed when a noxious stimuli is applied -
ANS... -B
The nurse is caring for clients in the ED. Which client should the nurse assess
first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ANS... -A
A female pt has experienced an episode of myasthenic crisis. The nurse would
assess whether the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ANS... -C
A pt is being admitted to the neurologic ICU following an acute head injury that
has resulted in cerebral edema. When planning this pt's care, the nurse would
expect to administer what priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
b. Furosemide (Lasix)
c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ANS... -C
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
QUSTIONS AND 100% COREECT ANSWERS
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 Trendelenburg position - ANS... -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 - ANS... -A
What would the nurse suspect when hourly assessment of UO on a pt post
craniotomy exhibits a urine output from a catheter of 1,500mL for 2 consecutive
hours?
a. ruching syndrome
b. syndrome of inappropriate antidiuretic hormone (SIADH)
c. adrenal crisis
d. diabetes insipidus - ANS... -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 - ANS... -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 - ANS... -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. achieves as high a level of function as possible
b. enhances the quantity of the pt's life
c. teaches the family proper care of the pt
d. provides community assistance - ANS... -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 - ANS... -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 - ANS... -A, C, D, E
The nurse is caring for a pt w a brain tumor. What drug would the nurse expect to
be ordered to reduce the edema surrounding the tumor?
a. solumedrol
b. dextromethorphan
c. dexamethasone
d. furosemide - ANS... -C
The nurse is caring for a pt who sustained a moderate head injury following a
bicycle accident. The nurses most recent assessment reveals that the pt's respiratory
effort has increased. What is the nurses most appropriate response?
a. inform the care team and assess for further signs of possible increased ICP
b. administer bronchodilators and monitor the pt's LOC
c. increase the pt's bed height and reassess in 30 mins
d. administer a bolus of normal line as ordered - ANS... -A
,A pt has a poor prognosis after being involved in a motor vehicle accident resulting
in a head injury. As the pt's ICP increases and condition worsens, the nurse knows
to assess for indications of approaching death. These indications include which of
the following?
a. hemiplegia
b. dry mucous membranes
c. signs of internal bleeding
d. loss of brain stem reflexes - ANS... -D
When caring for a pt w increased ICP the nurse knows the importance of
monitoring for possible secondary complications, including syndrome of
inappropriate antidiuretic hormone (SIADH). What nursing interventions would
the nurse most likely initiate if the pt developed SIADH?
a. fluid restriction
b. transfusion of platelets
c. transfusion of fresh frozen plasma (FFP)
d. electrolyte restriction - ANS... -A
The pt w fibromyalgia is suffering from pain at 12 of the 18 identification sites,
including the neck & upper back & knees. The pt also reports non-refreshing sleep,
depression, & being anxious when dealing w multiple tasks. The nurse should
teach this pt about what treatments? Select all that apply:
a. Minimal aerobic exercise
b. Relaxation strategy (biofeedback)
c. Anti-seizure during phenytoin
d. Serotonin reuptake inhibitor (e.g. sertraline)
e. Establish a regular sleep pattern - ANS... -B, D, E
The nurse caring for a client w a head injury would recognize which assessment
finding as early signs of increased ICP? Select all that apply:
a. Kussmaul breathing
b. Projectile vomiting
c. Weakness in one extremity
d. Headache not aggravated by movement of straining
e. Decreased urine output
f. Papilledema - ANS... -A, C, D
A nurse caring for a client diagnosed to have head injury. Which of the following
situations needs intervention by the nurse?
, a. The padded side rails up
b. The bed is adjusted to low level
c. The client's spouse turns on the TV one hour in the afternoon and 3 hours in the
evening
d. The head of bed is elevated at 30 degree angle - ANS... -C
The critical care nurse is caring for a client w a head injury secondary to a
motorcycle accident who, on morning rounds, is responsive to painful stimulus and
assumes decorticate posturing. Two hours later, which data would warrant
immediate intervention by the nurse?
a. The client has purposeful movement when the nurse rubs the sternum
b. The client extends the upper and lower extremities in response to painful stimuli
c. The client is aimlessly thrashing in the bed when a noxious stimuli is applied -
ANS... -B
The nurse is caring for clients in the ED. Which client should the nurse assess
first?
a. The client w an epidural hematoma
b. The client who had a seizure who is in the postictal state
c. The client diagnosed w R/O encephalitis who has a headache
d. The client w multiple sclerosis who has scanning speech - ANS... -A
A female pt has experienced an episode of myasthenic crisis. The nurse would
assess whether the pt has precipitating factors such as:
a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Intake of fatty foods - ANS... -C
A pt is being admitted to the neurologic ICU following an acute head injury that
has resulted in cerebral edema. When planning this pt's care, the nurse would
expect to administer what priority medication?
a. Hydrochlorothiazide (HydroDIURIL)
b. Furosemide (Lasix)
c. Mannitol (Osmitrol)
d. Spriolactone (Aldactone) - ANS... -C
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
