Chamberlain University NR-325 Exam 2 (pdf) | 2026/2027 | Adult
Health II Q&A
1. A nurse is assessing a client with a leaking cerebral aneurysm. Which of
the following clinical manifestations would indicate the client is experiencing
an increase in intracranial pressure?
A) Headache and neck pain
B) Slurred speech and confusion
C) Alert and oriented to person, place, and time
D) Pupillary changes and a decreased level of consciousness
E) Both A and D
Correct Answer: Both A and D
Rationale: Increased intracranial pressure (ICP) is a life-threatening condition
that can result from a leaking cerebral aneurysm. Classic signs include a
severe headache, nuchal rigidity (neck pain and stiffness), pupillary changes
(such as dilation or sluggish response), and a decreasing level of
consciousness (LOC). The client may also experience nausea, vomiting, and
altered vital signs. An alert and oriented client would not indicate increased
ICP.
2. A client with multiple sclerosis (MS) is on vacation and experiences sudden
muscle weakness and fatigue. The caregiver calls the nurse for advice.
Which question is most important for the nurse to ask to identify a potential
trigger for this exacerbation?
A) "Is the client staying in a hotel or private home?"
B) "Has the client been able to get out of bed and perform any self-care?"
C) "Is there a drastic change in temperature between home and where the
client is on vacation?"
D) "Do you know if the client is experiencing any symptoms of an infection?"
,Correct Answer: "Is there a drastic change in temperature between home
and where the client is on vacation?"
Rationale: In multiple sclerosis, exacerbations can be triggered by heat
(Uhthoff's phenomenon) or cold. A drastic change in temperature is a
common trigger and should be assessed first. While infection is also a
trigger, the context of travel and a change in environment makes
temperature the most immediate question to ask.
3. A nurse walks into a client's room and discovers the client has a new facial
droop. Place the following actions in the correct priority order.
A) Transport client to computerized tomography (CT) department
B) Obtain blood glucose level
C) Notify the code stroke team
D) Complete a neurological assessment
A) C, D, B, A
B) A, C, B, D
C) C, B, D, A
D) B, C, A, D
Correct Answer: C, D, B, A
Rationale: The priority is to activate the stroke team immediately (C). The
nurse should then perform a rapid neurological assessment (D) to identify
deficits, followed by checking the blood glucose level (B) to rule out
hypoglycemia as a cause of the symptoms. Transporting to CT (A) is a critical
step but occurs after initial stabilization and notification.
,4. A nurse is caring for a client in the post-anesthesia care unit (PACU) who
just had a cholecystectomy. Which assessment is the priority?
A) Oxygen saturation
B) Bowel sounds
C) Temperature
D) Surgical dressing
Correct Answer: Oxygen saturation
Rationale: In the immediate post-operative period, the priority is to maintain
a patent airway and adequate oxygenation. Assessing oxygen saturation is
the priority to detect respiratory depression or hypoxemia. While the other
assessments are important, they are not as immediately life-threatening.
5. A nurse is planning education for a 60-year-old client with a family history
of colon cancer. What should the nurse include in the instructions?
A) Annual proctoscopy
B) Fecal occult blood test every 6 months
C) Annual prostate specific antigen (PSA) blood test
D) Colonoscopy every 10 years
Correct Answer: Colonoscopy every 10 years
Rationale: For clients at increased risk of colon cancer, such as those with a
family history, screening colonoscopy is recommended every 10 years
starting at age 50, or earlier if there is a strong family history. Fecal occult
blood testing is a less sensitive screening method.
, 6. A nurse is admitting a client who has experienced a stroke. The client's left
arm and leg are weak, and they have difficulty speaking. The nurse identifies
that the stroke most likely occurred in which area of the brain?
A) Left hemisphere
B) Right hemisphere
C) Brainstem
D) Cerebellum
Correct Answer: Right hemisphere
Rationale: The right hemisphere of the brain controls motor function on the
left side of the body. Damage to the right hemisphere can result in left-sided
weakness (hemiparesis) and spatial-perceptual deficits. While speech
difficulties are more common with left hemisphere damage, the primary
finding here is left-sided weakness.
7. A client is prescribed tissue plasminogen activator (tPA) for an acute
ischemic stroke. Which of the following is a contraindication for this
medication?
A) Onset of stroke symptoms within 3 hours
B) Blood pressure of 150/90 mm Hg
C) History of a previous stroke within 3 months
D) Client is alert and oriented
Correct Answer: History of a previous stroke within 3 months
Rationale: tPA is contraindicated in clients with a history of a previous stroke
within the last 3 months, as it increases the risk of intracranial hemorrhage.
tPA must be given within 4.5 hours of symptom onset. Blood pressure must
be controlled (typically < 185/110) before administration.
Health II Q&A
1. A nurse is assessing a client with a leaking cerebral aneurysm. Which of
the following clinical manifestations would indicate the client is experiencing
an increase in intracranial pressure?
A) Headache and neck pain
B) Slurred speech and confusion
C) Alert and oriented to person, place, and time
D) Pupillary changes and a decreased level of consciousness
E) Both A and D
Correct Answer: Both A and D
Rationale: Increased intracranial pressure (ICP) is a life-threatening condition
that can result from a leaking cerebral aneurysm. Classic signs include a
severe headache, nuchal rigidity (neck pain and stiffness), pupillary changes
(such as dilation or sluggish response), and a decreasing level of
consciousness (LOC). The client may also experience nausea, vomiting, and
altered vital signs. An alert and oriented client would not indicate increased
ICP.
2. A client with multiple sclerosis (MS) is on vacation and experiences sudden
muscle weakness and fatigue. The caregiver calls the nurse for advice.
Which question is most important for the nurse to ask to identify a potential
trigger for this exacerbation?
A) "Is the client staying in a hotel or private home?"
B) "Has the client been able to get out of bed and perform any self-care?"
C) "Is there a drastic change in temperature between home and where the
client is on vacation?"
D) "Do you know if the client is experiencing any symptoms of an infection?"
,Correct Answer: "Is there a drastic change in temperature between home
and where the client is on vacation?"
Rationale: In multiple sclerosis, exacerbations can be triggered by heat
(Uhthoff's phenomenon) or cold. A drastic change in temperature is a
common trigger and should be assessed first. While infection is also a
trigger, the context of travel and a change in environment makes
temperature the most immediate question to ask.
3. A nurse walks into a client's room and discovers the client has a new facial
droop. Place the following actions in the correct priority order.
A) Transport client to computerized tomography (CT) department
B) Obtain blood glucose level
C) Notify the code stroke team
D) Complete a neurological assessment
A) C, D, B, A
B) A, C, B, D
C) C, B, D, A
D) B, C, A, D
Correct Answer: C, D, B, A
Rationale: The priority is to activate the stroke team immediately (C). The
nurse should then perform a rapid neurological assessment (D) to identify
deficits, followed by checking the blood glucose level (B) to rule out
hypoglycemia as a cause of the symptoms. Transporting to CT (A) is a critical
step but occurs after initial stabilization and notification.
,4. A nurse is caring for a client in the post-anesthesia care unit (PACU) who
just had a cholecystectomy. Which assessment is the priority?
A) Oxygen saturation
B) Bowel sounds
C) Temperature
D) Surgical dressing
Correct Answer: Oxygen saturation
Rationale: In the immediate post-operative period, the priority is to maintain
a patent airway and adequate oxygenation. Assessing oxygen saturation is
the priority to detect respiratory depression or hypoxemia. While the other
assessments are important, they are not as immediately life-threatening.
5. A nurse is planning education for a 60-year-old client with a family history
of colon cancer. What should the nurse include in the instructions?
A) Annual proctoscopy
B) Fecal occult blood test every 6 months
C) Annual prostate specific antigen (PSA) blood test
D) Colonoscopy every 10 years
Correct Answer: Colonoscopy every 10 years
Rationale: For clients at increased risk of colon cancer, such as those with a
family history, screening colonoscopy is recommended every 10 years
starting at age 50, or earlier if there is a strong family history. Fecal occult
blood testing is a less sensitive screening method.
, 6. A nurse is admitting a client who has experienced a stroke. The client's left
arm and leg are weak, and they have difficulty speaking. The nurse identifies
that the stroke most likely occurred in which area of the brain?
A) Left hemisphere
B) Right hemisphere
C) Brainstem
D) Cerebellum
Correct Answer: Right hemisphere
Rationale: The right hemisphere of the brain controls motor function on the
left side of the body. Damage to the right hemisphere can result in left-sided
weakness (hemiparesis) and spatial-perceptual deficits. While speech
difficulties are more common with left hemisphere damage, the primary
finding here is left-sided weakness.
7. A client is prescribed tissue plasminogen activator (tPA) for an acute
ischemic stroke. Which of the following is a contraindication for this
medication?
A) Onset of stroke symptoms within 3 hours
B) Blood pressure of 150/90 mm Hg
C) History of a previous stroke within 3 months
D) Client is alert and oriented
Correct Answer: History of a previous stroke within 3 months
Rationale: tPA is contraindicated in clients with a history of a previous stroke
within the last 3 months, as it increases the risk of intracranial hemorrhage.
tPA must be given within 4.5 hours of symptom onset. Blood pressure must
be controlled (typically < 185/110) before administration.
