NUR2571 Professional Nursing II
Exam 4 Comprehensive Practice
Quiz
1. A nurse is caring for a patient in the ICU who is showing signs of increased intracranial
pressure (ICP). Which of the following is the earliest sign of increasing ICP?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Change in level of consciousness (LOC)
D. Decerebrate posturing
Correct Answer: C
Expert Explanation: A change in the level of consciousness is the most sensitive and
earliest indicator of increased ICP. Cushing’s triad and posturing are late signs.
2. A patient presents with a Glasgow Coma Scale (GCS) score of 7. How should the nurse
interpret this finding?
A. The patient is fully awake and oriented.
B. The patient has minor neurological impairment.
C. The patient is lethargic but follows commands.
D. The patient is in a coma and requires immediate airway protection.
,Correct Answer: D
Expert Explanation: A GCS score of 8 or less is generally considered indicative of a coma,
often requiring intubation to protect the airway.
3. A patient with a T4 spinal cord injury suddenly complains of a severe headache and has a
blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer PRN pain medication for the headache.
B. Lower the head of the bed to a flat position.
C. Assess the patient for bladder distention or fecal impaction.
D. Notify the physician to request an antihypertensive.
Correct Answer: C
Expert Explanation: These are signs of autonomic dysreflexia. The priority is to identify
and remove the noxious stimulus, most commonly a full bladder or bowel.
4. Which of the following cardiac rhythms requires immediate defibrillation?
A. Atrial Fibrillation
B. Sinus Bradycardia
C. Asystole
D. Ventricular Fibrillation
Correct Answer: D
, Expert Explanation: Ventricular Fibrillation and pulseless Ventricular Tachycardia are
shockable rhythms. Asystole is not a shockable rhythm.
5. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). Which
oxygenation finding is a hallmark of ARDS?
A. Respiratory alkalosis
B. Refractory hypoxemia
C. Increased pulmonary artery wedge pressure
D. Immediate response to low-flow oxygen
Correct Answer: B
Expert Explanation: Refractory hypoxemia, where oxygen levels stay low despite
increasing the fraction of inspired oxygen (FiO2), is a hallmark of ARDS.
6. Which electrolyte imbalance is most commonly associated with the development of
Torsades de Pointes?
A. Hypernatremia
B. Hypomagnesemia
C. Hypokalemia
D. Hypercalcemia
Correct Answer: B
Exam 4 Comprehensive Practice
Quiz
1. A nurse is caring for a patient in the ICU who is showing signs of increased intracranial
pressure (ICP). Which of the following is the earliest sign of increasing ICP?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Change in level of consciousness (LOC)
D. Decerebrate posturing
Correct Answer: C
Expert Explanation: A change in the level of consciousness is the most sensitive and
earliest indicator of increased ICP. Cushing’s triad and posturing are late signs.
2. A patient presents with a Glasgow Coma Scale (GCS) score of 7. How should the nurse
interpret this finding?
A. The patient is fully awake and oriented.
B. The patient has minor neurological impairment.
C. The patient is lethargic but follows commands.
D. The patient is in a coma and requires immediate airway protection.
,Correct Answer: D
Expert Explanation: A GCS score of 8 or less is generally considered indicative of a coma,
often requiring intubation to protect the airway.
3. A patient with a T4 spinal cord injury suddenly complains of a severe headache and has a
blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Administer PRN pain medication for the headache.
B. Lower the head of the bed to a flat position.
C. Assess the patient for bladder distention or fecal impaction.
D. Notify the physician to request an antihypertensive.
Correct Answer: C
Expert Explanation: These are signs of autonomic dysreflexia. The priority is to identify
and remove the noxious stimulus, most commonly a full bladder or bowel.
4. Which of the following cardiac rhythms requires immediate defibrillation?
A. Atrial Fibrillation
B. Sinus Bradycardia
C. Asystole
D. Ventricular Fibrillation
Correct Answer: D
, Expert Explanation: Ventricular Fibrillation and pulseless Ventricular Tachycardia are
shockable rhythms. Asystole is not a shockable rhythm.
5. A patient is admitted with Acute Respiratory Distress Syndrome (ARDS). Which
oxygenation finding is a hallmark of ARDS?
A. Respiratory alkalosis
B. Refractory hypoxemia
C. Increased pulmonary artery wedge pressure
D. Immediate response to low-flow oxygen
Correct Answer: B
Expert Explanation: Refractory hypoxemia, where oxygen levels stay low despite
increasing the fraction of inspired oxygen (FiO2), is a hallmark of ARDS.
6. Which electrolyte imbalance is most commonly associated with the development of
Torsades de Pointes?
A. Hypernatremia
B. Hypomagnesemia
C. Hypokalemia
D. Hypercalcemia
Correct Answer: B
