Name: Jennifer D.

Ambrosio
Block and Section: BSN 4-4

FINAL ACTIVITY IN NCMB418

1. Using the 5-point scale for neuromuscular assessment, the following results are obtained:
a. A and C indicate the need for passive ROM; B and D indicate active ROM

2. A critically-ill patient in the ICU is noted to be increasingly lethargic. What does this observation
mean?
a. Patient is experiencing a decline in central neurological function

3. The cerbrospinal fluid pressure is averaging 25 mmHg. This is an indication of which of the
following?
a. Increased, may indicate a serious compromise in cerebral perfusion

Rationale: Normal ICP is 0-15mm Hg. Increasing ICP causes decreased cerebral perfusion and
eventually brain cell death. An initial stage of compensation would probably be 15-20 mm Hg. in
which bloodflow diminishes and brain tissue contracts to help bring down pressure. When these
mechanisms fail, there can be cerebral damage.

4. A patient was documented to have Broca's aphasia. This means that the patient is unable to:
c. Form words making sense

Rationale: Patient’s with Broca’s aphasia struggle to form words due to damage to the front portion
of the language-dominant side of the brain.

5. Which best describes a critically-ill patient's mental status?

b. It refers to the patient’s wakefulness and ability to respond to the environment

6. Which best describes the level of consciousness of a critically-ill patient?

a. The patient’s wakefulness and ability to respond to the environment

7. Using the Glasgow Coma Scale, the nurse interprets these findings as which of the following:
c. Opens eyes to speech; decerebrate posture; and confused

8. According to the Monro-Kellie Hypothesis, which among the following compensates to achieve
equilibrium in the cranium?
a. Cerebrospinal fluid

Rationale: This relationship is known as the Monro-Kellie hypothesis. Normally either the blood or
CSF would shift out the cranium to compensate for increased volume of one of these three
components. The brain is noncompressible. The volume of these components must remain in
balance, not be low.

9. Which among the following altered levels of arousal best describe confusion?
a. Impaired decision making

10. Which among the following descriptions does NOT fit the level of coma?
a. Arousable with difficulty

11. Which of the following is an early indication of a deteriorating condition of a patient with
increased ICP?
c. Dilated fixed pupils

Rationale: Dilated and fixed pupils are often considered an early sign of increased ICP. As intracranial
pressure rises, it can compress the cranial nerves, affecting the pupillary response.

12. Which of the following statements is NOT true about intraventricular catheter monitoring?
a. It doesn’t penetrate cerebrum
Rationale: Intraventricular catheter monitoring involves the insertion of a catheter into the lateral
ventricles of the brain, which does penetrate the cerebrum. The catheter is used for monitoring
intracranial pressure (ICP) and draining cerebrospinal fluid.

13. A stroke with neurologic deficits that lasted for more than 24 hours, but are now resolving will
possibly indicate which stage of stroke?
c. Stroke in evolution

14. Which drug classification for seizure treatment inhibits sodium influx or depolarization along
the nerve fiber?
a. Hydantoins

15. Which patient assessment data will the nurse look for to consider a diagnosis of stroke?
d. The patient has difficulty recalling his dinner last night

Rationale: Memory difficulties or difficulty recalling recent events can be a neurological symptom
associated with stroke. It's important to note that the assessment of stroke involves a comprehensive
evaluation of various neurological signs and symptoms, and the presence of one or more of these
symptoms may suggest the need for further evaluation and diagnostic testing.

16. Mannitol (Osmitrol) can decrease intracranial pressure by which drug action?
a. Pulling fluid from the extravascular spaces into the blood

Rationale: Mannitol is an osmotic diuretic that works by drawing water from the extravascular
spaces (such as the brain tissue) into the bloodstream, reducing intracranial pressure. This helps to
decrease cerebral edema and improve overall intracranial dynamics.

17. Which drug classification for seizure treatment are considered to have high sedative effects and
may cause severe CNS depression?
a. Barbiturates

Rationale: Barbiturates, such as phenobarbital, are known for their sedative effects and potential
for CNS depression. They are sometimes used in the treatment of seizures but are less commonly
prescribed due to their side effect profile and the availability of newer antiepileptic medications
with a more favorable safety profile.

18. Which is referred to as a syndrome of massive imbalanced reflex sympathetic discharge

occurring in patients with spinal cord injury above the T5-T6 which causes a sudden rise of the
blood pressure?
a. Autonomic dysreflexia

19. Which of the following is true of spinal cord injury?

a. Respiratory problems is a primary consideration, especially if the injury happens above the level of C5.

Rationale: In spinal cord injury, injuries above the level of C5 can result in impaired or lost function
of the diaphragm and intercostal muscles, leading to respiratory problems

20. The nurse must consider which of the following when administering anticonvulsants?
D. All of the given

21. You are working in a neuro ward when the emergency department called for an admission of a
client with a frontal head injury. Medical diagnosis reveals a subdural hematoma. Which of the
following is the priority question you are to ask the emergency nurse?
B. “When did the injury occur?”

Rationale: Knowing the time of injury helps in determining the potential progression of symptoms
and guides the healthcare team in managing the case effectively.

22. Aside from assessing the client’s GCS on a client with brainstem injury, the nurse also plans to:
A. Check cranial nerve functioning and respiratory status.
Rationale: The brainstem is responsible for many vital functions, including control of cranial nerves
which are often assessed by various tests and respiratory functions. Monitoring these aspects can
provide valuable information about the integrity of the brainstem.

23. You observed that the client is in decerebrate posturing after eliciting pain. This position tells
the nurse that the client has a:
A. Dysfunction in the brain stem

24. The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The
nurse determines that the client has an adequate understanding if the client states that:
D. “The morning dose of the medication should be taken before a serum drug level is drawn.”

25. A client is admitted with cerebral contusion is confused, disoriented and restless. Which of the
following nursing diagnosis takes priority?
A. Risk for injury

Rationale: Characterized by loss of consciousness associated with stupor and confusion. effects of
injury, particularly hemorrhage and edema, peak after about 18 to 36 hours. these effects, which
can cause secondary effects resulting in increased ICP and possible herniation syndromes, are most
pronounced in temporal lobe contusions.

26. The nurse is assessing the motor function of unconscious client. The nurse would plan to use
which of the following to test the client’s peripheral response to pain?
A. Nail bed pressure

Rationale: Nail bed pressure is the basic test for peripheral response.

27. The nurse is caring for a client suffered from TBI with increased ICP. The patient’s relative
asked the nurse how they will know if the patient is not progressing well. The nurse’s appropriate
response would be:
C. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.

28. The client suffered from fall has clear fluid leaking from the nose following a basilar skull
fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
B. Separates into concentric rings and tests positive for glucose

Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull
fracture. CSF can be distinguished from other body fluids because the drainage will separate into
bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests
positive for glucose.

29. The nurse is caring for the client with brain injury who begins to experience seizure activity
while in bed. Which of the following actions by the nurse would be contraindicated:
C. Restraining the client’s limb

30. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord
injury. Which of the following observations by the nurse indicates that spinal shock persists?
D. Flaccid paralysis

Rationale: Resolution of spinal shock is occurring when there is return of reflexes, a state of
hyperreflexia rather than flaccidity and reflex of emptying the bladder

31. The nurse has completed discharge instructions for the client with application of a halo device.
The nurse determines that the client needs further clarification of the instruction if the client states
that he or she will:
C. Drive only during the daytime

Rationale: Clients wearing a halo device should generally avoid driving until the device is removed.
The halo device can significantly restrict the range of motion and may affect the individual's ability
to operate a vehicle safely.
32. An unresponsive and pulseless client is brought into the emergency room after being in a car
accident and a neck injury is suspected. The nurse opens the client’s airway by which method?
A. Jaw-thrust maneuver

Rationale: The jaw-thrust maneuver is used to open the airway while avoiding movement of the
cervical spine. This technique is essential when there is a suspicion of neck injury to prevent further
damage to the spinal cord.

33. A nurse is caring for a client with a thoracic spinal cord injury. As part of the nursing care plan,
the nurse monitors for spinal shock. In the event that spinal shock occurs, the nurse anticipates that
the most likely intravenous (IV) fluid to be prescribed would be:
D. 0.9 % normal saline

34. A client with a spinal cord injury is at risk of developing foot drop. The nurse uses which of the
following as the most effective preventive measure?
A. Posterior leaf splint
B. Heel protectors
C. Pneumatic boots
D. Foot board

35. A client is ambulatory and wearing a halo vest after a cervical spine fracture. The nurse tells the
client to avoid which of the following because the client has a risk for injury?
B. Bending at the waist

36. A nurse is performing an assessment on a client who has a suspected spinal cord injury. Which
of the following is the priority nursing assessment?
C. Respiratory status

Rationale: Highest priority

37. A nurse is caring for a client who is newly diagnosed with a spinal cord injury. The nurse would
anticipate that the most likely medication to be prescribed would be:
D. Dexamethasone (Decadron)

Rationale: Dexamethasone is a corticosteroid that is often administered to reduce inflammation and

swelling in the spinal cord following a spinal cord injury. This can help minimize secondary damage
and improve outcomes.

38. A nurse is planning care for a client with a T-3 spinal cord injury. The nurse includes which
intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
A. Assist the client to develop a daily bowel routine to prevent constipation

39. A student is caring for a client who suffered massive blood loss after trauma. How does the
student correlate the blood loss with the client's mean arterial pressure (MAP)?
D. Lower blood volume lowers MAP.

40. A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12
to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed
4 hours ago. What action by the nurse is best?
A. Assess the client's tissue perfusion further.

Rationale: Signs of the earliest stage of shock are subtle and may manifest in slight increases in
heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the
normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators
of perfusion.

41. Nurse Kris gets the hand-off report on four clients. Which client should the nurse Kris assess
first?
A. Client with urine output of 40 mL/hr for the last 2 hours
Rationale: A decrease in urine output may indicate decreased renal perfusion, which is a critical
concern. The kidneys are sensitive to changes in blood flow, and decreased urine output can be an
early sign of inadequate cardiac output or other issues affecting perfusion.

42. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of
208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What
response by the nurse is best?
B. High glucose is common in shock and needs to be treated.

Rationale: High glucose readings are common in shock, and best outcomes are the result of treating them and
maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but
this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.

43. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3,
blood glucose level 198 mg/dL, and temperature 96.2°F (35.6°C). What action by the nurse takes
priority?
D. Notify the health care provider immediately.

44. A nurse works at a community center for older adults. What self-management measure can the
nurse teach the clients to prevent shock?
A. Do not get dehydrated in warm weather

Rationale: Preventing dehydration in older adults is important because the age -related decrease in
the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a
regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst) .

45. A client arrives in the emergency department after being in a car crash with fatalities. The
client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes
priority?
B. Apply direct pressure to the bleeding.

Rationale: Airway is the priority, followed by breathing and circulation (IVs and direct pressure).
Obtaining consent is done by the physician.

46. A client is receiving norepinephrine (Levophed) for shock. What assessment finding best
indicates a therapeutic effect from this drug?
B. Alert and oriented, answering questions

Rationale: Normal cognitive function is a good indicator that the client is receiving the benefits of
norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion.
Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not
indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally
so.

47. A nurse is caring for several clients at risk for septic shock. Which laboratory value requires the
nurse to communicate with the health care provider?
D. Lactate: 6 mmol/L

Rationale: A lactate level of 6 mmol/L is high and is indicative of possible shock.

48. A client in shock has been started on dopamine. What assessment finding requires the nurse to
communicate with the provider immediately?
C. Report of chest heaviness

Rationale: Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of
dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to
increased myocardial workload, and may cause ischemia. Without knowing the clients previous
blood pressure or pedal pulses, there is not enough information to determine if these are an
improvement or not. A urine output of 32 mL/hr is acceptable.

49. The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do
within 3 hours of the client being identified as being at risk? Select all that apply.
A. 1,2,3

Rationale: Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate)
serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the
cultures have been obtained). Infusing vasopressors and measuring central venous pressure are
actions that should occur within the first 6 hours.

50. The student nurse studying shock understands that the common manifestations of this condition
are directly related to which problems? Select all that apply.
A. 1,2

Rationale: The common manifestations of shock, no matter the cause, are directly related to the
effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and
increased perfusion are not manifestations of shock.

51. An adult’s shirt catches on fire and is now in flames. He panics and runs into his neighbor’s
yard. Which of the following is appropriate? Select all that apply.
D. 1,2,3,4

52. The nurse is caring for a man admitted with severe burns sustained when his clothing caught
fire while he was burning leaves. During the acute burn phase, the nurse explains to the man that
his nursing care plan is directed toward all of the following except:
A. Frequent and routine administration of narcotics

53. The nurse is planning care for an adult man who is admitted with severe flame burns. Nursing
care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by;
D. Fluid shift from plasma to interstitial spaces

Rationale: During the first 24-48 hours post-burn, a burn injury triggers a systemic inflammatory
response. This response leads to an increase in capillary permeability, causing fluid to shift from the
intravascular (plasma) space to the interstitial spaces. This fluid shift can result in edema and
decreased circulating blood volume. As a result, burn patients are at risk of hypovolemic shock
during this initial period.

54. The nurse is caring for an adult who was admitted following severe burns sustained in a house
fire. The nurse understands that an acceptable range for hourly urine output during the first 2 days
post-burn is:
C. 30-50 Ml

Rationale: Maintaining an adequate urine output is essential to assess renal perfusion and prevent
acute kidney injury in burn patients. However, the specific target may vary based on individual
patient characteristics and the extent of burn injuries. It's important for the healthcare team to
closely monitor fluid balance and adjust fluid administration accordingly based on the patient's
response. In severe burn cases, additional interventions and assessments are often required to
prevent complications related to fluid and electrolyte imbalances.

55. An adult has undergone skin graft from his left buttock to his right upper thigh. When caring
for the recipient site the nurse can expect to:
B. Assess for bleeding and large amount of fluid accumulation beneath the graft.

Rationale: After a skin graft, it is crucial to monitor the recipient site for signs of complications such
as bleeding and fluid accumulation. This helps to identify and address any issues that may affect the
graft's success.

56. A client with a skin graft has undergone a full thickness skin graft from her right upper thigh to
her upper chest area. The most appropriate nursing action in caring for her donor site is to:
C. Maintain the comprehension bandage on her right upper thigh for several days

Rationale: Compression bandages are often used to reduce swelling and support the graft site. They
help minimize the risk of hematoma formation and promote adherence of the graft to the recipient
site. Keeping the compression bandage in place for several days is a common practice in the care of
skin graft donor sites.
57. A client with a skin graft has undergone a full thickness skin graft from her right upper thigh to
her upper chest area. The most appropriate nursing action in caring for her donor site is to:
C. Small amount of serum beneath the graft

Rationale: It is normal to observe a small amount of serum (clear fluid) beneath the graft during the
initial stages of healing. This is part of the normal healing process, and it helps to keep the graft
moist. Continuous bleeding or significant amounts of blood beneath the graft would be concerning
and may require immediate attention. A meshed pattern in the graft is a technique used to expand
the graft, and it is not related to caring for the donor site.

58. A 78-year-old man is admitted with severe flame burns resulting from smoking in bed. The
nurse can expect his room environment to include:
C. Strict isolation techniques and policies

59. BONUS

60. A 23-year-old factory worker was burned severely in an industrial accident. He has second
degree burns on his right leg and arm and on his back. He has third degree burns on his left arm.
The triage nurse, using the rule of nines, estimates the extent of the client's burns as ____%.
B. 45%

61. An adult was burned in the house fire 16 hours ago. She suffered second and third degree burns
over 65% of her body. She is receiving lactated Ringers at 200 ml/h. which intervention is a priority
at this time?
A. Monitoring hourly urine output

Rationalea: Fluid resuscitation is a priority in the first 24 hours after a burn to prevent the onset of
shock and system collapse; urine output is the most readily available and reliable indicator for
determining the adequacy of fluid replacement. Pain is a high priority, but measures to preserve life
must be a priority. Assessing for infection is important. However, during the shock phase, measures
to preserve life must be a priority. Hourly ROM cannot occur until after the client is stabilized.

62. A nurse is providing care for a severely burned client during the shock phase of the burn injury.
Which assessment findings would indicate that the client is receiving adequate fluid volume
replacement?
B. Urine output 50mL/h, BP 100/60, oriented to person and place

Rationale: Fluid replacement is considered adequate when urine output is 30-50 mL/hr or 0.5
mL/kg/hr, blood pressure is stable, pulses are palpable, central venous pressure (CVP) is 7-10, and
potassium level is 3.5-5.3. A clear sensorium is another positive sign of adequate fluid replacement.
Weight gain is not an issue with fluid resuscitation.

63. A client with severe burns is receiving IV Zantac. Which statement best explains the reason for
administration of this medication in this situation?
D. The medication is an H2 receptor antagonist and will decrease acid secretion

64. An 18-year-old was burned 6 weeks ago. She is now ready for discharge. Select the statement
best reflecting understanding of discharge care:
B. “I will need to call my doctor if my temperature goes up or this burn area starts draining and oozing”

65. A client has suffered a chemical burn. The best initial action is to:
C. Flush the area with copious amount of water or normal saline

66. A 25-year-old electrical worker has come in contact with a live power line. He is unconscious
and is lying across the power line. The best initial action is to:
B. Grab the person and pull him away from the power lines.

67. Ten-year-old Eloise has second-degree burns. Nurse Lora who is caring for her must thoroughly
reassess these burns every:
A. 48 hours
68. Wound dressing to use for 10-year-old Eloise who has second-degree burns would be:
A. Fine mesh gauze
B. Non-adhesive dressing with gauze padding
C. Gauze Bandage Roll
D. Indoplas Absorbent Gauze pads

69. The emergency medical service has transported a client with severe chest pain. As the client is
being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing,
and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing
assistant?
D. Doing chest compressions

Rationale: Trained in basic cardiac life support and can perform chest compressions.

70. Following an emergency endotracheal intubation, nurses must verify tube placement and secure
the tube. To perform this function, she must perform the required sequence of:
A. 1,2,3,4
Rationale: Auscultating and confirming equal bilateral breath sounds should be performed in rapid
succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube
placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-
ray study.

71. A nurse has just admitted to a nursing unit a client with a traumatic brain injury who is at risk
for increased intracranial pressure. Pending specific physician prescriptions, the nurse would safely
place the client in which positions?
A. 1,2,4

Rationale: The head of a client with increased intracranial pressure should be kept in a neutral
midline position. The nurse should avoid flexing or extending the client's neck or turning the head
from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions
promotes venous drainage from the cranium to keep intracranial pressure down

72. The nurse responds to a certain call for help from the EMERGENCY DEPARTMENT waiting
area. There is an elderly patient lying on the floor. The first action of the nurse to perform must be:
B. Establish unresponsiveness

The Answer is B: Establish unresponsiveness first (the client may have fallen and sustained a minor
injury). If the client is unresponsive, get help and activate the code team.

73. An anxious female client complains of chest tightness, tingling sensations, and palpitations.
Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should
the nurse do first?
B. Have the client breathe into a brown paper bag

74. Which statement below is INCORRECT about the yellow triage tag color with regard to a
disaster situation?
D. A survivor with this tag color is seen after patients with the green tag color.

Rationale: This statement is INCORRECT. It should say: A survivor with this tag color is seen after
patients with the RED (not green) tag color.

75. A senior high school male student was sent to the emergency unit following an abrasion on his
face and a small laceration on the forehead. The client says he can’t move both his lower
extremities. Vital signs revealed a respiratory rate of 18, strong pulses, and capillary refill time of
less than 2 seconds. Which triage category would this client be assigned to?
D. Yellow

Rationale: The client is possibly suffering from a spinal injury but otherwise. has a stable status and can
communicate so the appropriate tag is YELLOW.
76. Using the START algorithm, identify the correct color tag for each given patient condition: The
wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can’t
follow simple commands. The wounded victim is assigned what tag color?
A. Red

77. You’re working as a triage nurse during a disaster situation. Based on the triage color code tags
placed on each of the wounded, which tag color represents the wounded who have the highest
priority of being treated first?
C. Red

Ratiionale: Red. The red tag indicates the patient must be seen first because they have life-
threatening injuries, but could survive if treated quickly. The patient is still alive but there is a
severe alteration in their breathing, circulation, or mental status that requires immediate medical
attention.

78. Miguel is a nurse helping in a triage unit for the survivors of catastrophic disaster from a
nearby province. One of the wounded individuals can able to walk around and has minor
lacerations on the arms, hands, trunk, and legs. What should be the color tag that the nurse should
place on this survivor?
D. Green

Rationale: Green tags are for patients who have MINOR injuries. If the patient can walk around
they are tagged as green. Sometimes they are referred to as the “walking wounded”.

79. While triaging the wounded from a disaster, you note that one of the wounded is not breathing,
radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What
color tag is assigned?
A. Black

Rationale: Black. The black tag is placed on the wounded that are dying or have expired. The
injuries are so severe that death is imminent. There is severe alteration or absence of breathing,
circulation, and neuro status.

80. The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second,
and is able to obey your commands. The wounded victim is assigned what tag color?
B. Yellow