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NSG 4100 EXAM 4 2025 | ALL QUESTIONS AND
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A nurse is planning the care of a 28y/o woman hospitalized w a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this pt? a. all at one time, to provide a longer rest period b. before meals, to stimulate her appetite c. in the morning, w frequent rest periods c. before bedtime, to promote rest ---------CORRECT ANSWER----------------
- C The nurse is developing a plan of care for a pt w Guillain-Barr syndrome. Which of the following interventions should the nurse prioritize for this pt? a. using the incentive spirometer as prescribed b. maintaining the pt on bed rest c. providing aids to compensate for loss of vision d. assessing frequently for loss of cognitive function ---------CORRECT ANSWER-----------------A A 69 y/o pt is brought to the ED bc a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis & admits the pt to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply: a. BP greater than 140/90 mm Hg b. HR greater than 120 bpm c. older age d. low Glasgow scale e. lack of previous immunizations ---------CORRECT ANSWER----------------- B, C, D
The critical care nurse is caring for a 25 y/o man admitted to the ICU w a brain abscess. What is a priority nursing responsibility in the care of the pt? a. maintaining the pt's functional independence b. providing health education c. monitoring neurologic status closely d. promoting mobility ---------CORRECT ANSWER-----------------C A pt is being admitted to the neurologic ICU w suspected herpes simplex virus encephalitis. What nursing action best addresses the pt's complaints of headache? a. initiating a patient-controlled analgesia (PCA) of morphine sulfate b. administering hydromorphone (Dilaudid) IV as needed c. dimming the lights and reducing stimulation d. distracting the pt w activity ---------CORRECT ANSWER-----------------C A pt is admitted through the ED w suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? a. serial assessments of hemoglobin levels b. blood glucose monitoring c. close monitoring of fluid balance d. assessment of pain along dermatomes ---------CORRECT ANSWER------ -----------C You are the clinic nurse caring for a pt w a recent diagnosis of myasthenia gravis. The pt has begun treatment w pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? a. increased muscle strength b. decreased pain c. improved GI function d. improved cognition ---------CORRECT ANSWER-----------------A
The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way? a. through a central venous line b. by a gravity infusion IV set c. by IV push for rapid onset of action d. mixed w parenteral feedings to balance osmosis ---------CORRECT ANSWER-----------------A The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient? a. anaphylaxis b. decreased oxygen consumption c. abdominal compartment syndrome d. decreased serum osmolality ---------CORRECT ANSWER-----------------C A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patients care? a. communicate clearly & frequently w the pt's family b. taper down interventions slowly when the prognosis worsens c. transfer the pt to a subacute unit when recovery appears unlikely d. ask the pt's family how they would prefer treatment to proceed --------- CORRECT ANSWER-----------------A A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patients plan of care while the patient is ventilated? a. performing frequent oral care b. maintinas pt in supine position c. suctioning pt q15mins unless contraindicated
d. administering prophylactic abx, as ordered ---------CORRECT ANSWER- ----------------A A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patients mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. a. Blood urea nitrogen (BUN) level b. urine specific gravity c. alkaline phosphatase level d. creatinine level e. serum albumin level ---------CORRECT ANSWER-----------------A, B, D An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patients infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patients risk of septic shock? a. apply an antibiotic ointment to the pt's mucous membranes, as ordered b. perform passive ROM exercises unless contraindicated c. initiate total parenteral nutrition (TPN) d. remove invasive devices as soon as they are no longer needed --------- CORRECT ANSWER-----------------D A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care? a. the increase in cultural diversity in the US b. staffing shortages in healthcare and questions concerning quality of care c. increased costs of healthcare coupled w inequalities in access d. ability of technology to prolong life beyond meaningful quality of life ------- --CORRECT ANSWER-----------------D
The nurse has observed that an older adult patient with a diagnosis of end- stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond? a. privately ask the son to allow the pt to make his own healthcare decisions b. explain to the pt that he is responsible for his own decisions c. work w the team to negotiate informed consent d. avoid divulging info to the eldest son ---------CORRECT ANSWER--------- --------C One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category? a. uplifting memories b. ignoring negative outcomes c. envisioning one specific outcome d. avoiding any actual or potential threat ---------CORRECT ANSWER-------- ---------A A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim? a. To prioritize emotional needs b. To prevent and relieve suffering c. To bridge between curative care and hospice care d. To provide care while there is still hope ---------CORRECT ANSWER------ -----------B
A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patients care in this setting be based? A) Meaningful living during terminal illness requires technologic interventions. B) Meaningful living during terminal illness is best supported in designated facilities. C) Meaningful living during terminal illness is best supported in the home. D) Meaningful living during terminal illness is best achieved by prolonging physiologic dying. ---------CORRECT ANSWER-----------------C A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer patients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. A) Financial pressures on health care providers B) Patient reluctance to accept this type of care C) Strong association of hospice care with prolonging death D) Advances in curative treatment in late-stage illness E) Ease of making a terminal diagnosis ---------CORRECT ANSWER--------- --------A, B, D The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care? A) Aggressively continuing to fight the disease process B) Moving the patient to a long-term care facility when it becomes necessary C) Including the children in planning their fathers care D) Supporting the patients and familys values and choices --------- CORRECT ANSWER-----------------D
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 ---------CORRECT ANSWER-----------------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 ---------CORRECT ANSWER-----------------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 --------- CORRECT ANSWER-----------------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 ---------CORRECT ANSWER-----------------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) ---------CORRECT ANSWER-----------------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 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 ANSWER----- ------------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 ANSWER-----------------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 ANSWER-----------------C
d. venous doppler studies ---------CORRECT ANSWER-----------------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 ANSWER-----------------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 ANSWER------ -----------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 ANSWER----- ------------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 ANSWER-----------------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 ANSWER---- -------------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 ANSWER-----------------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 ANSWER----------------- 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
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 ---------CORRECT ANSWER-----------------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 ---------CORRECT ANSWER-----------------A A pt is recovering from an intracranial surgery performed approximately 24 hrs ago and is complaining of a headache that the pt rates at 8 on a 10- point pain scale. What nursing action is most appropriate? a. administer morphine sulfate as ordered b. reposition the pt in a prone position c. apply a hot pack to the pt's scalp d. implement distraction techniques ---------CORRECT ANSWER-------------- ---A A pt is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the LOC is slightly decreased w the day of surgery. What is the nurses best response to this assessment finding? a. recognize that this may represent the peak of post-surgical cerebral edema b. alert the surgeon to the possibility of an intracranial hemorrhage
c. understand that the surgery may have been unsuccessful d. recognize the need to refer the pt to the palliative care team --------- CORRECT ANSWER-----------------A A pt w a cerebral aneurysm exhibits s/s of an increase in ICP. What nursing intervention would be the most appropriate for this pt? a. ROM exercises to prevent contractors b. encouraging independence w ADLs to promote recovery c. early initiation of physical therapy d. absolute bed rest in a quiet, non stimulating environment --------- CORRECT ANSWER-----------------D A pt has been admitted to the ICU after being recently diagnosed w an aneurysm and the pt's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the pt's plan of care? a. elevate the HOB to 45 degrees b. maintain the pt on complete bed rest c. administer enemas when the pt is constipated d. avoid use of thigh-high elastic compression stockings ---------CORRECT ANSWER-----------------B A pt diagnosed w a cerebral aneurysm reports a severe HA to the nurse. What action is a priority for the nurse? a. sit w the pt for a few minutes b. administer an analgesic c. inform the nurse-manager d. call the physician immediately ---------CORRECT ANSWER----------------- D When caring for a pt who has had a stroke, a priority is reduction of ICP. What pt position is most consistent w this goal?
A nurse is caring for a critically ill pt w autonomic dysreflexia. What clinical manifestations would the nurse expect in this pt? a. respiratory distress & projectile vomiting b. bradycardia & HTN c. tachycardia & agitation d. third-spacing & hyperthermia ---------CORRECT ANSWER-----------------B The nurse is caring for a pt w increased ICP caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the pt may be experiencing increased brain compression causing brains temp damage? a. hyperthermia b. tachycardia c. HTN d. bradypnea ---------CORRECT ANSWER-----------------A A pt is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the pt fell, she was knocked out, but came back and seemed okay. Now she is c/o a severe HA and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? a. insertion of an intracranial monitoring device b. treatment w antihypertensives c. emergency craniotomy d. administration of anticoagulant therapy ---------CORRECT ANSWER------ -----------C The staff educator is precasting a nurse new to the critical care unit when a pt w a T2 spinal cord injury is admitted. The pt is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the pt closely, what would be the nurses most appropriate action? a. prepare to transfuse packed red blood cells b. prepare for interventions to increase the pt's BP c. place the pt in the Trendelenberg position
d. prepare an ice bath to lower core body temperature ---------CORRECT ANSWER-----------------B An ED nurse has just received a call from EMS that they are transporting a 17 y/o man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? a. sports-related injuries b. acts of violence c. injuries due to a fall d. motor vehicle accidents ---------CORRECT ANSWER-----------------D A pt w spinal cord injury has a nursing dx of altered mobility & the nurse recognizes the increased risk for DVT. Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? a. pacing the pt on a fluid restriction as ordered b. applying thigh-high elastic stockings c. administering an antifibriolyic agent d. assisting the pt w passive ROM exercises ---------CORRECT ANSWER-- ---------------B Paramedics have brought an intubated pt to the ED following a head injury due to acceleration-deceleration MVA. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? a. keep HOB flat at all times b. teach pt to perform the Valsalva maneuver c. administer benzodiazepines on a PRN basis d. perform endotracheal suctioning every hour ---------CORRECT ANSWER-----------------C
