Chamberlain University NR 325 Final Exam (pdf) | 2026/2027 | Adult
Health II Q&A
1. A nurse is assessing a client who sustained a traumatic brain injury (TBI).
Which of the following assessment findings is the priority?
A) Blood glucose level of 110 mg/dL
B) Decreased level of consciousness
C) Deep tendon reflexes 2+
D) Nutritional status
Correct Answer: Decreased level of consciousness
Rationale: Level of consciousness (LOC) is the single most important
assessment for a client with a TBI because it is the earliest and most
sensitive indicator of increasing intracranial pressure (ICP) and neurological
deterioration. Other assessments are important but secondary to monitoring
LOC.
2. A client with an acute ischemic stroke is being evaluated for thrombolytic
therapy with tissue plasminogen activator (tPA). Which of the following is an
absolute contraindication for tPA administration?
A) Onset of stroke symptoms within 3 hours
B) Blood pressure of 150/90 mm Hg
C) History of a previous stroke within the last 3 months
D) Client is alert and oriented
Correct Answer: History of a previous stroke within the last 3 months
Rationale: tPA is contraindicated in clients with a history of a previous stroke
within the last 3 months due to the increased risk of intracranial hemorrhage.
,tPA must be given within 4.5 hours of symptom onset, and blood pressure
must be controlled (typically < 185/110) before administration.
3. A nurse is teaching the family of a client with Alzheimer's disease about
managing agitation. Which of the following instructions should the nurse
include?
A) "Use loud, firm commands to get the client's attention."
B) "Maintain a calm and consistent environment."
C) "Encourage the client to make all decisions independently."
D) "Use physical restraints to prevent wandering."
Correct Answer: "Maintain a calm and consistent environment."
Rationale: Clients with Alzheimer's disease often become agitated when
overstimulated or confused. Maintaining a calm and consistent environment
can help reduce agitation. The client should be approached calmly and with
reassurance. Restraints should be avoided.
4. 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
Correct Answer: Pupillary changes and a decreased level of consciousness
Rationale: Increased intracranial pressure (ICP) 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).
5. A client who has experienced a stroke has weakness on the left side of the
body and 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.
6. A nurse is caring for a client in the postictal phase of a seizure. Which of
the following findings should the nurse expect?
A) Tonic-clonic activity
B) Confusion and drowsiness
C) Aura
D) Loss of consciousness
Correct Answer: Confusion and drowsiness
Rationale: The postictal phase is the period immediately following a seizure,
during which the brain recovers. This phase is characterized by confusion,
, drowsiness, fatigue, and headache. The preictal phase occurs before the
seizure, and the ictal phase is the seizure itself.
7. A client with Parkinson's disease is prescribed levodopa-carbidopa. Which
of the following adverse effects should the nurse monitor for?
A) Dyskinesia
B) Hypertension
C) Hypoglycemia
D) Sedation
Correct Answer: Dyskinesia
Rationale: Levodopa is the mainstay of treatment for Parkinson's disease. A
common adverse effect of long-term levodopa therapy is dyskinesia, which
are involuntary, abnormal movements. Hypotension, not hypertension, can
also occur.
8. A nurse is caring for a client with a complete spinal cord injury at the T4
level. The client suddenly develops a pounding headache, facial flushing,
nasal congestion, and a blood pressure of 240/130 mmHg. Which action
should the nurse take first?
A) Administer prescribed antihypertensive medication immediately
B) Place the patient in a high-Fowler's position
C) Increase intravenous fluid administration
D) Encourage the patient to lie flat and rest
Correct Answer: Place the patient in a high-Fowler's position
Rationale: The client is experiencing autonomic dysreflexia, a life-threatening
condition characterized by severe hypertension, headache, and diaphoresis
Health II Q&A
1. A nurse is assessing a client who sustained a traumatic brain injury (TBI).
Which of the following assessment findings is the priority?
A) Blood glucose level of 110 mg/dL
B) Decreased level of consciousness
C) Deep tendon reflexes 2+
D) Nutritional status
Correct Answer: Decreased level of consciousness
Rationale: Level of consciousness (LOC) is the single most important
assessment for a client with a TBI because it is the earliest and most
sensitive indicator of increasing intracranial pressure (ICP) and neurological
deterioration. Other assessments are important but secondary to monitoring
LOC.
2. A client with an acute ischemic stroke is being evaluated for thrombolytic
therapy with tissue plasminogen activator (tPA). Which of the following is an
absolute contraindication for tPA administration?
A) Onset of stroke symptoms within 3 hours
B) Blood pressure of 150/90 mm Hg
C) History of a previous stroke within the last 3 months
D) Client is alert and oriented
Correct Answer: History of a previous stroke within the last 3 months
Rationale: tPA is contraindicated in clients with a history of a previous stroke
within the last 3 months due to the increased risk of intracranial hemorrhage.
,tPA must be given within 4.5 hours of symptom onset, and blood pressure
must be controlled (typically < 185/110) before administration.
3. A nurse is teaching the family of a client with Alzheimer's disease about
managing agitation. Which of the following instructions should the nurse
include?
A) "Use loud, firm commands to get the client's attention."
B) "Maintain a calm and consistent environment."
C) "Encourage the client to make all decisions independently."
D) "Use physical restraints to prevent wandering."
Correct Answer: "Maintain a calm and consistent environment."
Rationale: Clients with Alzheimer's disease often become agitated when
overstimulated or confused. Maintaining a calm and consistent environment
can help reduce agitation. The client should be approached calmly and with
reassurance. Restraints should be avoided.
4. 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
Correct Answer: Pupillary changes and a decreased level of consciousness
Rationale: Increased intracranial pressure (ICP) 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).
5. A client who has experienced a stroke has weakness on the left side of the
body and 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.
6. A nurse is caring for a client in the postictal phase of a seizure. Which of
the following findings should the nurse expect?
A) Tonic-clonic activity
B) Confusion and drowsiness
C) Aura
D) Loss of consciousness
Correct Answer: Confusion and drowsiness
Rationale: The postictal phase is the period immediately following a seizure,
during which the brain recovers. This phase is characterized by confusion,
, drowsiness, fatigue, and headache. The preictal phase occurs before the
seizure, and the ictal phase is the seizure itself.
7. A client with Parkinson's disease is prescribed levodopa-carbidopa. Which
of the following adverse effects should the nurse monitor for?
A) Dyskinesia
B) Hypertension
C) Hypoglycemia
D) Sedation
Correct Answer: Dyskinesia
Rationale: Levodopa is the mainstay of treatment for Parkinson's disease. A
common adverse effect of long-term levodopa therapy is dyskinesia, which
are involuntary, abnormal movements. Hypotension, not hypertension, can
also occur.
8. A nurse is caring for a client with a complete spinal cord injury at the T4
level. The client suddenly develops a pounding headache, facial flushing,
nasal congestion, and a blood pressure of 240/130 mmHg. Which action
should the nurse take first?
A) Administer prescribed antihypertensive medication immediately
B) Place the patient in a high-Fowler's position
C) Increase intravenous fluid administration
D) Encourage the patient to lie flat and rest
Correct Answer: Place the patient in a high-Fowler's position
Rationale: The client is experiencing autonomic dysreflexia, a life-threatening
condition characterized by severe hypertension, headache, and diaphoresis
