NSG 430/ NSG430| Final Exam GCU | Adult Health
Nursing II | Questions & Answers with Rationale |
Grade A| 100% Correct | (NEW 2026/2027)
Question 1
A client with a traumatic brain injury has an ICP of 22 mmHg. The nurse should FIRST:
A) Document the finding as normal
B) Notify the healthcare provider
C) Administer mannitol
D) Elevate the head of the bed to 30 degrees
Correct Answer: D
Rationale: Normal ICP is 0-15 mmHg. Elevating the HOB to 30 degrees is an independent
nursing intervention that promotes venous drainage and lowers ICP. While the provider should
be notified, this is the first action the nurse can take independently.
Question 2
A client with a head injury develops decerebrate posturing. The nurse should:
A) Document the finding
B) Notify the healthcare provider immediately
C) Continue to monitor
D) Administer pain medication
Correct Answer: B
Rationale: Decerebrate (extensor) posturing indicates severe brainstem damage and requires
immediate notification of the healthcare provider. This finding suggests worsening neurological
status and potential herniation.
Question 3
The nurse is assessing a client with meningitis. Which finding requires immediate intervention?
A) Fever of 101.2°F
B) Complaints of headache
C) Photophobia
D) New onset of seizures
Correct Answer: D
,Rationale: New onset seizures in meningitis indicate increasing intracranial pressure or cortical
irritation and represent a neurological emergency requiring immediate intervention. Seizures
can lead to further brain damage and must be treated promptly.
Question 4
A client with a history of seizures begins experiencing a generalized tonic-clonic seizure. What is
the nurse's PRIORITY action?
A) Restrain the client's limbs
B) Place a tongue blade in the mouth
C) Turn the client to the side
D) Leave the client to call a rapid response
Correct Answer: C
Rationale: Turning the client to the side (lateral recumbent position) helps maintain a patent
airway and allows secretions to drain, preventing aspiration. Restraints and tongue blades are
contraindicated during a seizure.
Question 5
A client with Parkinson's disease is having difficulty performing activities of daily living. Which
referral is most appropriate?
A) Physical Therapy
B) Occupational Therapy
C) Speech Therapy
D) Hospice
Correct Answer: B
Rationale: Occupational Therapy focuses on helping clients perform activities of daily living
(ADLs) such as feeding, dressing, and grooming. Physical Therapy focuses on gross motor skills
and mobility.
Question 6
A client with a traumatic brain injury has an ICP of 22 mmHg. Which medication would the
nurse anticipate administering?
A) Mannitol
B) Furosemide
C) Dopamine
D) Epinephrine
Correct Answer: A
,Rationale: Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid from the brain
into the vascular space. It is a first-line medication for increased ICP.
Question 7
A client is admitted with a stroke. The nurse should place the client in which position?
A) Head of bed elevated 30 degrees
B) Supine with head flat
C) Trendelenburg position
D) Left side-lying only
Correct Answer: A
Rationale: HOB elevation to 30 degrees reduces ICP and promotes venous drainage while
maintaining adequate cerebral perfusion pressure. Flat positioning increases ICP.
Question 8
A client with a stroke has difficulty swallowing. Which referral should the nurse initiate?
A) Physical therapy
B) Speech-language pathology
C) Occupational therapy
D) Respiratory therapy
Correct Answer: B
Rationale: Speech-language pathologists evaluate and treat swallowing disorders (dysphagia).
This is essential to prevent aspiration in stroke patients.
Question 9
A client with Alzheimer's disease is pacing and becoming agitated. Which intervention should
the nurse implement first?
A) Place the client in seclusion
B) Apply a vest restraint
C) Acknowledge the client's feelings and redirect to an activity
D) Administer an as-needed sedative
Correct Answer: C
Rationale: Least restrictive interventions should be used first. Acknowledging feelings and
redirecting to a safe activity is therapeutic and appropriate. Restraints and seclusion are last
resorts and require provider orders.
, Question 10
A client with a spinal cord injury at T6 develops sudden hypertension, bradycardia, and severe
headache. What is the nurse's priority action?
A) Administer antihypertensive medication
B) Elevate the head of the bed
C) Notify the healthcare provider
D) Administer pain medication
Correct Answer: B
Rationale: These symptoms indicate autonomic dysreflexia, a life-threatening emergency. The
priority is to elevate the HOB to lower blood pressure and identify the triggering stimulus (e.g.,
full bladder, fecal impaction).
SECTION 2: MUSCULOSKELETAL DISORDERS (Questions 46-90)
Question 46
A client with a fractured femur. Which assessment finding requires immediate notification of
the healthcare provider?
A) Pain at the fracture site
B) Temperature of 99.2°F (37.3°C)
C) Paresthesia of the toes on the affected leg
D) Ecchymosis around the fracture site
Correct Answer: C
Rationale: Paresthesia suggests neurovascular compromise, which can be caused by
compartment syndrome. This is a medical emergency requiring immediate intervention to
prevent permanent tissue damage.
Question 47
A client with a cast reports numbness and tingling in the toes. The nurse should:
A) Document the finding
B) Notify the healthcare provider
C) Apply heat to the cast
D) Administer pain medication
Correct Answer: B
Nursing II | Questions & Answers with Rationale |
Grade A| 100% Correct | (NEW 2026/2027)
Question 1
A client with a traumatic brain injury has an ICP of 22 mmHg. The nurse should FIRST:
A) Document the finding as normal
B) Notify the healthcare provider
C) Administer mannitol
D) Elevate the head of the bed to 30 degrees
Correct Answer: D
Rationale: Normal ICP is 0-15 mmHg. Elevating the HOB to 30 degrees is an independent
nursing intervention that promotes venous drainage and lowers ICP. While the provider should
be notified, this is the first action the nurse can take independently.
Question 2
A client with a head injury develops decerebrate posturing. The nurse should:
A) Document the finding
B) Notify the healthcare provider immediately
C) Continue to monitor
D) Administer pain medication
Correct Answer: B
Rationale: Decerebrate (extensor) posturing indicates severe brainstem damage and requires
immediate notification of the healthcare provider. This finding suggests worsening neurological
status and potential herniation.
Question 3
The nurse is assessing a client with meningitis. Which finding requires immediate intervention?
A) Fever of 101.2°F
B) Complaints of headache
C) Photophobia
D) New onset of seizures
Correct Answer: D
,Rationale: New onset seizures in meningitis indicate increasing intracranial pressure or cortical
irritation and represent a neurological emergency requiring immediate intervention. Seizures
can lead to further brain damage and must be treated promptly.
Question 4
A client with a history of seizures begins experiencing a generalized tonic-clonic seizure. What is
the nurse's PRIORITY action?
A) Restrain the client's limbs
B) Place a tongue blade in the mouth
C) Turn the client to the side
D) Leave the client to call a rapid response
Correct Answer: C
Rationale: Turning the client to the side (lateral recumbent position) helps maintain a patent
airway and allows secretions to drain, preventing aspiration. Restraints and tongue blades are
contraindicated during a seizure.
Question 5
A client with Parkinson's disease is having difficulty performing activities of daily living. Which
referral is most appropriate?
A) Physical Therapy
B) Occupational Therapy
C) Speech Therapy
D) Hospice
Correct Answer: B
Rationale: Occupational Therapy focuses on helping clients perform activities of daily living
(ADLs) such as feeding, dressing, and grooming. Physical Therapy focuses on gross motor skills
and mobility.
Question 6
A client with a traumatic brain injury has an ICP of 22 mmHg. Which medication would the
nurse anticipate administering?
A) Mannitol
B) Furosemide
C) Dopamine
D) Epinephrine
Correct Answer: A
,Rationale: Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid from the brain
into the vascular space. It is a first-line medication for increased ICP.
Question 7
A client is admitted with a stroke. The nurse should place the client in which position?
A) Head of bed elevated 30 degrees
B) Supine with head flat
C) Trendelenburg position
D) Left side-lying only
Correct Answer: A
Rationale: HOB elevation to 30 degrees reduces ICP and promotes venous drainage while
maintaining adequate cerebral perfusion pressure. Flat positioning increases ICP.
Question 8
A client with a stroke has difficulty swallowing. Which referral should the nurse initiate?
A) Physical therapy
B) Speech-language pathology
C) Occupational therapy
D) Respiratory therapy
Correct Answer: B
Rationale: Speech-language pathologists evaluate and treat swallowing disorders (dysphagia).
This is essential to prevent aspiration in stroke patients.
Question 9
A client with Alzheimer's disease is pacing and becoming agitated. Which intervention should
the nurse implement first?
A) Place the client in seclusion
B) Apply a vest restraint
C) Acknowledge the client's feelings and redirect to an activity
D) Administer an as-needed sedative
Correct Answer: C
Rationale: Least restrictive interventions should be used first. Acknowledging feelings and
redirecting to a safe activity is therapeutic and appropriate. Restraints and seclusion are last
resorts and require provider orders.
, Question 10
A client with a spinal cord injury at T6 develops sudden hypertension, bradycardia, and severe
headache. What is the nurse's priority action?
A) Administer antihypertensive medication
B) Elevate the head of the bed
C) Notify the healthcare provider
D) Administer pain medication
Correct Answer: B
Rationale: These symptoms indicate autonomic dysreflexia, a life-threatening emergency. The
priority is to elevate the HOB to lower blood pressure and identify the triggering stimulus (e.g.,
full bladder, fecal impaction).
SECTION 2: MUSCULOSKELETAL DISORDERS (Questions 46-90)
Question 46
A client with a fractured femur. Which assessment finding requires immediate notification of
the healthcare provider?
A) Pain at the fracture site
B) Temperature of 99.2°F (37.3°C)
C) Paresthesia of the toes on the affected leg
D) Ecchymosis around the fracture site
Correct Answer: C
Rationale: Paresthesia suggests neurovascular compromise, which can be caused by
compartment syndrome. This is a medical emergency requiring immediate intervention to
prevent permanent tissue damage.
Question 47
A client with a cast reports numbness and tingling in the toes. The nurse should:
A) Document the finding
B) Notify the healthcare provider
C) Apply heat to the cast
D) Administer pain medication
Correct Answer: B
