NUR 390 Exam 3 – Nursing Care of Adult I – 2025 Actual
Questions and Answers – Concordia University St. Paul
A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and
does not respond to a verbal command to move but attempts to push away a painful stimulus.
How would the nurse record the patient's Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15 - ANSWER>>b. 11
The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor
response.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,
and flexion of the arms, how would the nurse report the response?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing - ANSWER>>c. Decorticate posturing
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as
decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the
flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
An athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will
the nurse collect to determine whether the patient is developing postconcussion syndrome?
,a. Short-term memory
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light - ANSWER>>a. Short-term memory
Decreased short-term memory, persistent headache, lethargy, personality and behavior
changes, shortened attention span, and changes in intellectual ability are indications of
postconcussion syndrome. The other data may be assessed but are not indications of
postconcussion syndrome.
When assessing a patient who has a right frontal lobe tumor, which finding would the nurse
expect?
a. Expressive aphasia
b. Impaired judgment
c. Right-sided weakness
d. Difficulty swallowing - ANSWER>>b. Impaired judgment
The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the
parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor.
Swallowing is controlled by the brainstem.
When assessing an adult who has bacterial meningitis, the nurse obtains the following data.
Which finding requires the most immediate intervention?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernig's sign.
c. The patient's temperature is 101F (38.3C).
,d. The patient's blood pressure is 88/42 mm Hg. - ANSWER>>d. The patient's blood pressure is
88/42 mm Hg.
Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the
need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's
sign are expected with bacterial meningitis. The nurse should intervene to lower the
temperature, but this is not as life threatening as the hypotension.
Which topic would the nurse anticipate teaching a patient who had a brief episode of tinnitus,
diplopia, and dysarthria with no residual effects?
a. Cerebral aneurysm clipping
b. Heparin intravenous infusion
c. Oral low-dose aspirin therapy
d. Tissue plasminogen activator (tPA) - ANSWER>>c. Oral low-dose aspirin therapy
The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that
inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin
infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms
are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for
TIA.
A patient is being admitted with a possible stroke. Which information from the nursing
assessment indicates that the patient is more likely to be having a hemorrhagic stroke than a
thromboembolic stroke?
a. The patient has intermittent bouts of atrial fibrillation.
b. The patient has had brief episodes of right-sided hemiplegia.
c. The patient has a history of treatment for infective endocarditis.
d. The patient reports that the symptoms began with a severe headache. - ANSWER>>d. The
patient reports that the symptoms began with a severe headache.
, A sudden onset headache is typical of a subarachnoid hemorrhage. Atrial fibrillation and
infective endocarditis are a risk factors for thrombotic or embolic stroke. Brief episodes of right-
sided hemiplegia are consistent with transient ischemic attack and risk for embolic stroke.
A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and
leg paralysis. Which other finding would the nurse expect?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions - ANSWER>>d. Difficulty comprehending instructions
Right-sided paralysis indicates a left-brain stroke, which is also associated with difficulty in
comprehension and use of language: the left hemisphere is dominant for language skills in
right-handed persons and in most left-handed persons. Impulsive behavior and neglect are
more likely with a right-side stroke. The left-side reflexes are likely to be intact.
The health record indicates that a patient has an occluded left posterior cerebral artery. Which
finding would the nurse anticipate?
a. Dysphasia
b. Confusion
c. Visual deficits
d. Poor judgment - ANSWER>>c. Visual deficits
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with
middle cerebral artery involvement. Cognitive deficits and changes in judgment are more
typical of anterior cerebral artery occlusion.
Questions and Answers – Concordia University St. Paul
A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and
does not respond to a verbal command to move but attempts to push away a painful stimulus.
How would the nurse record the patient's Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15 - ANSWER>>b. 11
The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor
response.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,
and flexion of the arms, how would the nurse report the response?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing - ANSWER>>c. Decorticate posturing
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as
decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the
flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
An athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will
the nurse collect to determine whether the patient is developing postconcussion syndrome?
,a. Short-term memory
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light - ANSWER>>a. Short-term memory
Decreased short-term memory, persistent headache, lethargy, personality and behavior
changes, shortened attention span, and changes in intellectual ability are indications of
postconcussion syndrome. The other data may be assessed but are not indications of
postconcussion syndrome.
When assessing a patient who has a right frontal lobe tumor, which finding would the nurse
expect?
a. Expressive aphasia
b. Impaired judgment
c. Right-sided weakness
d. Difficulty swallowing - ANSWER>>b. Impaired judgment
The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the
parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor.
Swallowing is controlled by the brainstem.
When assessing an adult who has bacterial meningitis, the nurse obtains the following data.
Which finding requires the most immediate intervention?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernig's sign.
c. The patient's temperature is 101F (38.3C).
,d. The patient's blood pressure is 88/42 mm Hg. - ANSWER>>d. The patient's blood pressure is
88/42 mm Hg.
Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the
need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's
sign are expected with bacterial meningitis. The nurse should intervene to lower the
temperature, but this is not as life threatening as the hypotension.
Which topic would the nurse anticipate teaching a patient who had a brief episode of tinnitus,
diplopia, and dysarthria with no residual effects?
a. Cerebral aneurysm clipping
b. Heparin intravenous infusion
c. Oral low-dose aspirin therapy
d. Tissue plasminogen activator (tPA) - ANSWER>>c. Oral low-dose aspirin therapy
The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that
inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin
infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms
are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for
TIA.
A patient is being admitted with a possible stroke. Which information from the nursing
assessment indicates that the patient is more likely to be having a hemorrhagic stroke than a
thromboembolic stroke?
a. The patient has intermittent bouts of atrial fibrillation.
b. The patient has had brief episodes of right-sided hemiplegia.
c. The patient has a history of treatment for infective endocarditis.
d. The patient reports that the symptoms began with a severe headache. - ANSWER>>d. The
patient reports that the symptoms began with a severe headache.
, A sudden onset headache is typical of a subarachnoid hemorrhage. Atrial fibrillation and
infective endocarditis are a risk factors for thrombotic or embolic stroke. Brief episodes of right-
sided hemiplegia are consistent with transient ischemic attack and risk for embolic stroke.
A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and
leg paralysis. Which other finding would the nurse expect?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions - ANSWER>>d. Difficulty comprehending instructions
Right-sided paralysis indicates a left-brain stroke, which is also associated with difficulty in
comprehension and use of language: the left hemisphere is dominant for language skills in
right-handed persons and in most left-handed persons. Impulsive behavior and neglect are
more likely with a right-side stroke. The left-side reflexes are likely to be intact.
The health record indicates that a patient has an occluded left posterior cerebral artery. Which
finding would the nurse anticipate?
a. Dysphasia
b. Confusion
c. Visual deficits
d. Poor judgment - ANSWER>>c. Visual deficits
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with
middle cerebral artery involvement. Cognitive deficits and changes in judgment are more
typical of anterior cerebral artery occlusion.
