NSG430 Exam 3 V2 | NSG 430 Adult Health
Nursing II | Grand Canyon University
This study guide is intended to provide comprehensive preparation for adult health nursing
assessments related to neurological care, orthopedic nursing, and complex adult medical
conditions. The content reflects practical nursing concepts commonly tested in nursing
examinations.
This version contains realistic exam-style questions designed to strengthen understanding of
adult disease management, nursing assessment findings, and therapeutic interventions. Detailed
expert explanations support concept mastery and practical nursing application.
════════════════════════════════════
The Exam Covers:
• Increased intracranial pressure
• Spinal cord injury nursing care
• Arthritis and joint disorders
• Osteoporosis management
• Blood transfusion nursing care
• Hematologic laboratory interpretation
• Mobility and safety interventions
• Postoperative orthopedic nursing care
════════════════════════════════════
1. A nurse is caring for a patient with increased intracranial pressure (ICP). Which of the
following nursing interventions is most appropriate to help decrease ICP?
A. Place the patient in a Trendelenburg position
B. Perform frequent suctioning to clear the airway
C. Encourage the patient to perform isometric exercises
D. Maintain the head of the bed at 30 to 45 degrees
Correct Answer: D
,Expert Explanation: Maintaining the head of the bed at 30 to 45 degrees promotes venous
drainage from the brain. This helps to reduce intracranial pressure by utilizing gravity. The
nurse should also ensure the patient’s neck is kept in a neutral position to avoid
obstructing jugular veins.
2. A patient with a spinal cord injury at the T4 level reports a sudden, severe headache and is
found to have a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Assess the patient for bladder distention
B. Administer an ordered analgesic for the headache
C. Place the patient in a flat, supine position
D. Notify the healthcare provider immediately
Correct Answer: A
Expert Explanation: The patient is exhibiting signs of autonomic dysreflexia, which is
often triggered by a full bladder or impacted bowel. The priority is to identify and remove
the stimulus, starting with the bladder. The nurse should also elevate the head of the bed to
help lower the blood pressure while assessing the cause.
3. A nurse is educating a client about the prevention of osteoporosis. Which of the following
recommendations should the nurse include?
A. Engage in swimming for 30 minutes daily
B. Increase intake of phosphorus-rich foods
C. Limit sun exposure to prevent skin damage
, D. Participate in regular weight-bearing exercises
Correct Answer: D
Expert Explanation: Weight-bearing exercises, such as walking or weightlifting, stimulate
bone remodeling and increase bone density. Swimming is a non-weight-bearing exercise
and is less effective for bone health. Adequate calcium and vitamin D intake are also
essential components of osteoporosis prevention.
4. A patient receiving a unit of packed red blood cells (PRBCs) begins to experience chills,
fever, and lower back pain. Which action should the nurse take first?
A. Stop the transfusion immediately
B. Administer diphenhydramine as ordered
C. Slow the infusion rate and monitor vital signs
D. Check the patient’s temperature and blood pressure
Correct Answer: A
Expert Explanation: Chills, fever, and back pain are classic symptoms of an acute
hemolytic transfusion reaction. The nurse’s first priority must be to stop the infusion to
prevent further administration of the incompatible blood. After stopping the infusion, the
nurse should maintain the IV line with normal saline and notify the provider.
5. Which laboratory result would the nurse expect to see in a patient with a diagnosis of
Rheumatoid Arthritis (RA)?
A. Decreased erythrocyte sedimentation rate (ESR)
Nursing II | Grand Canyon University
This study guide is intended to provide comprehensive preparation for adult health nursing
assessments related to neurological care, orthopedic nursing, and complex adult medical
conditions. The content reflects practical nursing concepts commonly tested in nursing
examinations.
This version contains realistic exam-style questions designed to strengthen understanding of
adult disease management, nursing assessment findings, and therapeutic interventions. Detailed
expert explanations support concept mastery and practical nursing application.
════════════════════════════════════
The Exam Covers:
• Increased intracranial pressure
• Spinal cord injury nursing care
• Arthritis and joint disorders
• Osteoporosis management
• Blood transfusion nursing care
• Hematologic laboratory interpretation
• Mobility and safety interventions
• Postoperative orthopedic nursing care
════════════════════════════════════
1. A nurse is caring for a patient with increased intracranial pressure (ICP). Which of the
following nursing interventions is most appropriate to help decrease ICP?
A. Place the patient in a Trendelenburg position
B. Perform frequent suctioning to clear the airway
C. Encourage the patient to perform isometric exercises
D. Maintain the head of the bed at 30 to 45 degrees
Correct Answer: D
,Expert Explanation: Maintaining the head of the bed at 30 to 45 degrees promotes venous
drainage from the brain. This helps to reduce intracranial pressure by utilizing gravity. The
nurse should also ensure the patient’s neck is kept in a neutral position to avoid
obstructing jugular veins.
2. A patient with a spinal cord injury at the T4 level reports a sudden, severe headache and is
found to have a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Assess the patient for bladder distention
B. Administer an ordered analgesic for the headache
C. Place the patient in a flat, supine position
D. Notify the healthcare provider immediately
Correct Answer: A
Expert Explanation: The patient is exhibiting signs of autonomic dysreflexia, which is
often triggered by a full bladder or impacted bowel. The priority is to identify and remove
the stimulus, starting with the bladder. The nurse should also elevate the head of the bed to
help lower the blood pressure while assessing the cause.
3. A nurse is educating a client about the prevention of osteoporosis. Which of the following
recommendations should the nurse include?
A. Engage in swimming for 30 minutes daily
B. Increase intake of phosphorus-rich foods
C. Limit sun exposure to prevent skin damage
, D. Participate in regular weight-bearing exercises
Correct Answer: D
Expert Explanation: Weight-bearing exercises, such as walking or weightlifting, stimulate
bone remodeling and increase bone density. Swimming is a non-weight-bearing exercise
and is less effective for bone health. Adequate calcium and vitamin D intake are also
essential components of osteoporosis prevention.
4. A patient receiving a unit of packed red blood cells (PRBCs) begins to experience chills,
fever, and lower back pain. Which action should the nurse take first?
A. Stop the transfusion immediately
B. Administer diphenhydramine as ordered
C. Slow the infusion rate and monitor vital signs
D. Check the patient’s temperature and blood pressure
Correct Answer: A
Expert Explanation: Chills, fever, and back pain are classic symptoms of an acute
hemolytic transfusion reaction. The nurse’s first priority must be to stop the infusion to
prevent further administration of the incompatible blood. After stopping the infusion, the
nurse should maintain the IV line with normal saline and notify the provider.
5. Which laboratory result would the nurse expect to see in a patient with a diagnosis of
Rheumatoid Arthritis (RA)?
A. Decreased erythrocyte sedimentation rate (ESR)
