NSG430 Exam 3 V1 | NSG 430 Adult Health
Nursing II | Grand Canyon University
This exam preparation resource is designed to help students strengthen their understanding of
neurological disorders, musculoskeletal conditions, and hematologic nursing care in adult
patients. The material emphasizes clinical nursing management, patient safety, and evidence-
based interventions in acute care settings.
The questions included in this version are structured to closely mirror the actual course exam
format and level of difficulty. Detailed expert explanations are included to improve clinical
judgment, prioritization skills, and nursing knowledge.
════════════════════════════════════
The Exam Covers:
• Neurological assessment
• Stroke nursing management
• Seizure disorders
• Musculoskeletal disorders
• Fracture and orthopedic care
• Hematologic disorders
• Pain management strategies
• Rehabilitation nursing concepts
════════════════════════════════════
1. A nurse is assessing a patient with a traumatic brain injury and finds the patient has a
Glasgow Coma Scale (GCS) score of 7. Which action should the nurse prioritize?
A. Monitor urine output hourly
B. Prepare for endotracheal intubation
C. Assess the patient’s nutritional status
D. Perform a range of motion exercises
Correct Answer: B
,Expert Explanation: A Glasgow Coma Scale score of 8 or less is generally indicative of a
coma and suggests that the patient cannot maintain their own airway. Intubation is
prioritized to ensure adequate ventilation and prevent hypoxia which could worsen brain
injury. The nurse must act quickly to stabilize the respiratory status before addressing
secondary assessments.
2. Which clinical manifestation should a nurse recognize as the earliest sign of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Change in level of consciousness
C. Cushing’s triad
D. Fixed and dilated pupils
Correct Answer: B
Expert Explanation: A change in the level of consciousness is the most sensitive and
earliest indicator of increased intracranial pressure. As pressure rises, brain tissue
perfusion is compromised, leading to agitation, confusion, or lethargy. Late signs include
Cushing’s triad and pupillary changes, which indicate impending herniation.
3. A patient who suffered a stroke three days ago is experiencing homonymous hemianopsia.
Which nursing intervention is most appropriate?
A. Place the patient’s food tray on the side with the visual field deficit
B. Teach the patient to scan the environment by turning the head
,C. Encourage the patient to keep both eyes closed to rest
D. Patch the affected eye to prevent double vision
Correct Answer: B
Expert Explanation: Homonymous hemianopsia is the loss of half of the visual field in
both eyes, which can lead to neglecting one side of the environment. Teaching the patient
to scan the environment helps them compensate for the loss of vision and improves safety
during activities like eating or walking. Placing items on the affected side would likely lead
to them being ignored or missed entirely.
4. The nurse is caring for a patient experiencing a tonic-clonic seizure. What is the priority
nursing action?
A. Insert a tongue blade into the patient’s mouth
B. Restrain the patient’s limbs to prevent injury
C. Administer oral anticonvulsants immediately
D. Turn the patient to a side-lying position
Correct Answer: D
Expert Explanation: Turning the patient to a side-lying position is critical to maintaining a
patent airway and preventing aspiration of saliva or vomitus. The nurse should never place
objects in the mouth or restrain the patient as these actions can cause further injury. Once
the seizure concludes, the nurse should continue to monitor the airway and assess the
post-ictal state.
, 5. Which medication is considered the gold standard for the acute management of status
epilepticus?
A. Lorazepam
B. Valproic acid
C. Phenytoin
D. Gabapentin
Correct Answer: A
Expert Explanation: Benzodiazepines like Lorazepam or Diazepam are the first-line
treatments for status epilepticus because they act quickly to stop seizure activity in the
brain. Phenytoin is often administered afterward for long-term seizure control but is not
the fastest-acting agent for an acute emergency. Status epilepticus is a medical emergency
that requires immediate pharmacological intervention to prevent brain damage.
6. A patient with a history of seizures is prescribed Phenytoin. Which side effect should the
nurse include in the discharge teaching?
A. Increased appetite
B. Gingival hyperplasia
C. Urinary retention
D. Hypertension
Correct Answer: B
Nursing II | Grand Canyon University
This exam preparation resource is designed to help students strengthen their understanding of
neurological disorders, musculoskeletal conditions, and hematologic nursing care in adult
patients. The material emphasizes clinical nursing management, patient safety, and evidence-
based interventions in acute care settings.
The questions included in this version are structured to closely mirror the actual course exam
format and level of difficulty. Detailed expert explanations are included to improve clinical
judgment, prioritization skills, and nursing knowledge.
════════════════════════════════════
The Exam Covers:
• Neurological assessment
• Stroke nursing management
• Seizure disorders
• Musculoskeletal disorders
• Fracture and orthopedic care
• Hematologic disorders
• Pain management strategies
• Rehabilitation nursing concepts
════════════════════════════════════
1. A nurse is assessing a patient with a traumatic brain injury and finds the patient has a
Glasgow Coma Scale (GCS) score of 7. Which action should the nurse prioritize?
A. Monitor urine output hourly
B. Prepare for endotracheal intubation
C. Assess the patient’s nutritional status
D. Perform a range of motion exercises
Correct Answer: B
,Expert Explanation: A Glasgow Coma Scale score of 8 or less is generally indicative of a
coma and suggests that the patient cannot maintain their own airway. Intubation is
prioritized to ensure adequate ventilation and prevent hypoxia which could worsen brain
injury. The nurse must act quickly to stabilize the respiratory status before addressing
secondary assessments.
2. Which clinical manifestation should a nurse recognize as the earliest sign of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Change in level of consciousness
C. Cushing’s triad
D. Fixed and dilated pupils
Correct Answer: B
Expert Explanation: A change in the level of consciousness is the most sensitive and
earliest indicator of increased intracranial pressure. As pressure rises, brain tissue
perfusion is compromised, leading to agitation, confusion, or lethargy. Late signs include
Cushing’s triad and pupillary changes, which indicate impending herniation.
3. A patient who suffered a stroke three days ago is experiencing homonymous hemianopsia.
Which nursing intervention is most appropriate?
A. Place the patient’s food tray on the side with the visual field deficit
B. Teach the patient to scan the environment by turning the head
,C. Encourage the patient to keep both eyes closed to rest
D. Patch the affected eye to prevent double vision
Correct Answer: B
Expert Explanation: Homonymous hemianopsia is the loss of half of the visual field in
both eyes, which can lead to neglecting one side of the environment. Teaching the patient
to scan the environment helps them compensate for the loss of vision and improves safety
during activities like eating or walking. Placing items on the affected side would likely lead
to them being ignored or missed entirely.
4. The nurse is caring for a patient experiencing a tonic-clonic seizure. What is the priority
nursing action?
A. Insert a tongue blade into the patient’s mouth
B. Restrain the patient’s limbs to prevent injury
C. Administer oral anticonvulsants immediately
D. Turn the patient to a side-lying position
Correct Answer: D
Expert Explanation: Turning the patient to a side-lying position is critical to maintaining a
patent airway and preventing aspiration of saliva or vomitus. The nurse should never place
objects in the mouth or restrain the patient as these actions can cause further injury. Once
the seizure concludes, the nurse should continue to monitor the airway and assess the
post-ictal state.
, 5. Which medication is considered the gold standard for the acute management of status
epilepticus?
A. Lorazepam
B. Valproic acid
C. Phenytoin
D. Gabapentin
Correct Answer: A
Expert Explanation: Benzodiazepines like Lorazepam or Diazepam are the first-line
treatments for status epilepticus because they act quickly to stop seizure activity in the
brain. Phenytoin is often administered afterward for long-term seizure control but is not
the fastest-acting agent for an acute emergency. Status epilepticus is a medical emergency
that requires immediate pharmacological intervention to prevent brain damage.
6. A patient with a history of seizures is prescribed Phenytoin. Which side effect should the
nurse include in the discharge teaching?
A. Increased appetite
B. Gingival hyperplasia
C. Urinary retention
D. Hypertension
Correct Answer: B
