NURS 2500-Acute Exam 2 Study guide
Questions with Solved Solutions 2026
Updated.
The nurse is assessing the adaptation of a client to changes in functional status after a stroke
(brain attack). Which observation indicates to the nurse that the client is adapting most
successfully?
1. Gets angry with family if they interrupt a task
2. Experiences bouts of depression and irritability
3. Has difficulty with using modified feeding utensils
4. Consistently uses adaptive equipment in dressing self - Answer Answer: 4 Rationale:
Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make
appropriate lifestyle alterations, use the assistance of others, and have appropriate social
interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful
attempt to adapt.
The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous
hemianopsia about measures to help the client overcome the deficit. Which statement suggests
that the family understands the measures to use when caring for the client?
1. "We need to discourage wearing eyeglasses."
2. "We need to place objects in the impaired field of vision."
3. "We need to approach from the impaired field of vision."
4. "We need to encourage head turning to scan the lost visual field." - Answer Answer: 4
Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with
homonymous hemianopsia needs to have objects placed in the intact field of vision, and the
nurse also would approach the client from the intact side. The nurse instructs the client to scan
the environment to overcome the visual deficit and does client teaching from within the intact
field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse is caring for a client who begins to experience seizure activity while in bed, which
actions would the nurse take? SATA
1. Loosening restrictive clothing.
2. Restraining the client's limbs.
3. Removing the pillow and raising the padded side rails.
4. Position the client to the side, is possible, with the head flexed forward.
5. Keeping the curtain around the client and the room door open so that when help arrives,
they can quickly enter to assist. - Answer Answer: 1, 3, 4 Rationale: Nursing actions during a
seizure include providing for privacy, loosening restrictive clothing, removing the pillow and
raising padded side rails in the bed, and placing the client on one side with the head flexed
forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are
never restrained because the strong muscle contractions could cause the client harm. If the
, client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if
possible; protects the head from injury; and moves furniture that may injure the client
The nurse is instituting seizure precautions for a client who is being admitted from the
emergency department. Which measures would the nurse include in planning for the client's
safety? Select all that apply.
1. Padding the side rails of the bed.
2. Placing an airway at the bedside.
3. Placing the bed in the high position.
4. Putting a padded tongue blade at the head of the bed.
5. Placing oxygen and suction equipment at the bedside.
6. Flushing the intravenous catheter to ensure that the site is patent. - Answer Answer: 1, 2,
5, 6 Rationale: Seizure precautions may vary from agency to agency, but they generally have
some common features. Usually, an airway, oxygen, and suctioning equipment are kept
available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest
position. The client has an intravenous access in place to have a readily accessible route if
antiseizure medications must be administered, and as part of the routine assessment the nurse
would be checking patency of the catheter. The use of padded tongue blades is highly
controversial, and they would not be kept at the bedside. Forcing a tongue blade into the mouth
during a seizure more likely will harm the client who bites down during seizure activity. Risks
include blocking the airway from improper placement, chipping the client's teeth, and
subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may
give the nurse enough time to place an oral airway before seizure activity begins.
The nurse provides information to the caregiver of a patient with epilepsy who has tonicclonic
seizures. Which statement by the caregiver indicates a need for further teaching?
A. "The jerking movements may last for 30 to 40 seconds."
B. "It is normal for a person to be sleepy after a seizure.
C. "I should call 911 if breathing slows during the seizure."
D. "Objects should not be placed in the mouth during a seizure." - Answer Answer: C.
Rationale: Caregivers do not need to call an ambulance or send a person to the hospital after a
single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive
injury has occurred. Altered breathing is a manifestation of a tonic-clonic seizure. Contact
emergency medical services (or call 911) if breathing stops for more than 30 seconds. No
objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is
common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic
phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.
Which characteristic would the nurse associate with a focal seizure?
A. The patient lost consciousness during the seizure.
B. The seizure involved both sides of the patient's brain.
C. The seizure involved lip smacking and repetitive movements.
Questions with Solved Solutions 2026
Updated.
The nurse is assessing the adaptation of a client to changes in functional status after a stroke
(brain attack). Which observation indicates to the nurse that the client is adapting most
successfully?
1. Gets angry with family if they interrupt a task
2. Experiences bouts of depression and irritability
3. Has difficulty with using modified feeding utensils
4. Consistently uses adaptive equipment in dressing self - Answer Answer: 4 Rationale:
Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make
appropriate lifestyle alterations, use the assistance of others, and have appropriate social
interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful
attempt to adapt.
The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous
hemianopsia about measures to help the client overcome the deficit. Which statement suggests
that the family understands the measures to use when caring for the client?
1. "We need to discourage wearing eyeglasses."
2. "We need to place objects in the impaired field of vision."
3. "We need to approach from the impaired field of vision."
4. "We need to encourage head turning to scan the lost visual field." - Answer Answer: 4
Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with
homonymous hemianopsia needs to have objects placed in the intact field of vision, and the
nurse also would approach the client from the intact side. The nurse instructs the client to scan
the environment to overcome the visual deficit and does client teaching from within the intact
field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse is caring for a client who begins to experience seizure activity while in bed, which
actions would the nurse take? SATA
1. Loosening restrictive clothing.
2. Restraining the client's limbs.
3. Removing the pillow and raising the padded side rails.
4. Position the client to the side, is possible, with the head flexed forward.
5. Keeping the curtain around the client and the room door open so that when help arrives,
they can quickly enter to assist. - Answer Answer: 1, 3, 4 Rationale: Nursing actions during a
seizure include providing for privacy, loosening restrictive clothing, removing the pillow and
raising padded side rails in the bed, and placing the client on one side with the head flexed
forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are
never restrained because the strong muscle contractions could cause the client harm. If the
, client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if
possible; protects the head from injury; and moves furniture that may injure the client
The nurse is instituting seizure precautions for a client who is being admitted from the
emergency department. Which measures would the nurse include in planning for the client's
safety? Select all that apply.
1. Padding the side rails of the bed.
2. Placing an airway at the bedside.
3. Placing the bed in the high position.
4. Putting a padded tongue blade at the head of the bed.
5. Placing oxygen and suction equipment at the bedside.
6. Flushing the intravenous catheter to ensure that the site is patent. - Answer Answer: 1, 2,
5, 6 Rationale: Seizure precautions may vary from agency to agency, but they generally have
some common features. Usually, an airway, oxygen, and suctioning equipment are kept
available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest
position. The client has an intravenous access in place to have a readily accessible route if
antiseizure medications must be administered, and as part of the routine assessment the nurse
would be checking patency of the catheter. The use of padded tongue blades is highly
controversial, and they would not be kept at the bedside. Forcing a tongue blade into the mouth
during a seizure more likely will harm the client who bites down during seizure activity. Risks
include blocking the airway from improper placement, chipping the client's teeth, and
subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may
give the nurse enough time to place an oral airway before seizure activity begins.
The nurse provides information to the caregiver of a patient with epilepsy who has tonicclonic
seizures. Which statement by the caregiver indicates a need for further teaching?
A. "The jerking movements may last for 30 to 40 seconds."
B. "It is normal for a person to be sleepy after a seizure.
C. "I should call 911 if breathing slows during the seizure."
D. "Objects should not be placed in the mouth during a seizure." - Answer Answer: C.
Rationale: Caregivers do not need to call an ambulance or send a person to the hospital after a
single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive
injury has occurred. Altered breathing is a manifestation of a tonic-clonic seizure. Contact
emergency medical services (or call 911) if breathing stops for more than 30 seconds. No
objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is
common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic
phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.
Which characteristic would the nurse associate with a focal seizure?
A. The patient lost consciousness during the seizure.
B. The seizure involved both sides of the patient's brain.
C. The seizure involved lip smacking and repetitive movements.
