,NSG 430 Exam 3 | Adult Health Nursing II | Grand
Canyon University | Q & A | 2026/2027 Edition (PDF)
1. A patient is admitted with a new diagnosis of ischemic stroke. The nurse knows that the time window
for administration of intravenous alteplase (tPA) is within:
A) 30 minutes of symptom onset
B) 3 hours of symptom onset (up to 4.5 hours in selected patients)
C) 6 hours of symptom onset
D) 12 hours of symptom onset
Correct Answer: 3 hours of symptom onset (up to 4.5 hours in selected patients)
Rationale: For acute ischemic stroke, IV tPA is approved within 3 hours of symptom onset; certain
patients may benefit up to 4.5 hours. Time is brain; earlier administration improves outcomes. The 3-
hour window is the standard for most patients, with an extended window for selected patients meeting
specific criteria.
2. The nurse is assessing a patient with a suspected stroke. Which finding is most consistent with a left
middle cerebral artery (MCA) stroke?
A) Left-sided neglect and left homonymous hemianopia
B) Right-sided weakness and aphasia
C) Ataxia and dysmetria
D) Bilateral lower extremity weakness
Correct Answer: Right-sided weakness and aphasia
Rationale: Left MCA stroke causes right hemiparesis and, if the dominant hemisphere is affected,
aphasia. Neglect and left-sided deficits are more common with right MCA strokes. Ataxia and dysmetria
suggest cerebellar involvement, and bilateral lower extremity weakness suggests spinal cord or bilateral
cerebral issues.
,3. A patient with a seizure disorder is prescribed phenytoin (Dilantin). The nurse should monitor which
laboratory value most closely?
A) Platelet count
B) Phenytoin level
C) Hemoglobin
D) Potassium
Correct Answer: Phenytoin level
Rationale: Phenytoin has a narrow therapeutic index (10–20 mcg/mL). Levels outside this range cause
toxicity or breakthrough seizures. Monitoring serum drug levels is essential to maintain therapeutic
efficacy and prevent adverse effects. While other labs are important, the drug level is the priority.
4. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mm Hg. The nurse
should:
A) Document as normal and continue monitoring
B) Notify the healthcare provider immediately
C) Elevate the head of the bed to 90 degrees
D) Administer a bolus of IV fluids
Correct Answer: Notify the healthcare provider immediately
Rationale: Normal ICP is 5–15 mm Hg; sustained ICP above 20 mm Hg is considered elevated and
requires intervention. The nurse should notify the healthcare provider immediately. Elevating the HOB
to 30 degrees (not 90) is appropriate, but notification is the priority. IV fluids would increase ICP.
5. Which nursing intervention is most important to prevent increased ICP in a client with a severe head
injury?
A) Keep the head of bed flat
B) Suction the airway every hour
C) Maintain the head and neck in neutral alignment
, D) Cluster all nursing activities to allow for longer rest periods
Correct Answer: Maintain the head and neck in neutral alignment
Rationale: Neck flexion or rotation impedes venous drainage from the brain, increasing ICP. Maintaining
neutral alignment promotes venous outflow, reducing cerebral blood volume and ICP. The head of bed
should be elevated to 30 degrees, and activities should be spaced out (not clustered) to prevent ICP
spikes.
6. A client with increased ICP has a Glasgow Coma Scale (GCS) score of 6. Which intervention would the
nurse anticipate?
A) Ambulate three times daily
B) Continuous electroencephalogram (EEG) monitoring
C) Provide the client with a low-stimulation environment
D) Scheduled doses of IV phenytoin (Dilantin)
Correct Answer: Scheduled doses of IV phenytoin (Dilantin)
Rationale: A GCS of 8 or less indicates severe brain injury. Seizures are common in these patients and
can worsen ICP. Phenytoin is an anticonvulsant often prescribed prophylactically for 7 days post-injury
to prevent seizure activity that could increase ICP.
7. A patient with intracranial pressure (ICP) monitoring has a sustained ICP of 25 mm Hg. Following the
standard protocol, the nurse should prepare to give which IV medication to reduce ICP?
A) Furosemide
B) Mannitol
C) Phenytoin
D) Naloxone
Correct Answer: Mannitol
Canyon University | Q & A | 2026/2027 Edition (PDF)
1. A patient is admitted with a new diagnosis of ischemic stroke. The nurse knows that the time window
for administration of intravenous alteplase (tPA) is within:
A) 30 minutes of symptom onset
B) 3 hours of symptom onset (up to 4.5 hours in selected patients)
C) 6 hours of symptom onset
D) 12 hours of symptom onset
Correct Answer: 3 hours of symptom onset (up to 4.5 hours in selected patients)
Rationale: For acute ischemic stroke, IV tPA is approved within 3 hours of symptom onset; certain
patients may benefit up to 4.5 hours. Time is brain; earlier administration improves outcomes. The 3-
hour window is the standard for most patients, with an extended window for selected patients meeting
specific criteria.
2. The nurse is assessing a patient with a suspected stroke. Which finding is most consistent with a left
middle cerebral artery (MCA) stroke?
A) Left-sided neglect and left homonymous hemianopia
B) Right-sided weakness and aphasia
C) Ataxia and dysmetria
D) Bilateral lower extremity weakness
Correct Answer: Right-sided weakness and aphasia
Rationale: Left MCA stroke causes right hemiparesis and, if the dominant hemisphere is affected,
aphasia. Neglect and left-sided deficits are more common with right MCA strokes. Ataxia and dysmetria
suggest cerebellar involvement, and bilateral lower extremity weakness suggests spinal cord or bilateral
cerebral issues.
,3. A patient with a seizure disorder is prescribed phenytoin (Dilantin). The nurse should monitor which
laboratory value most closely?
A) Platelet count
B) Phenytoin level
C) Hemoglobin
D) Potassium
Correct Answer: Phenytoin level
Rationale: Phenytoin has a narrow therapeutic index (10–20 mcg/mL). Levels outside this range cause
toxicity or breakthrough seizures. Monitoring serum drug levels is essential to maintain therapeutic
efficacy and prevent adverse effects. While other labs are important, the drug level is the priority.
4. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mm Hg. The nurse
should:
A) Document as normal and continue monitoring
B) Notify the healthcare provider immediately
C) Elevate the head of the bed to 90 degrees
D) Administer a bolus of IV fluids
Correct Answer: Notify the healthcare provider immediately
Rationale: Normal ICP is 5–15 mm Hg; sustained ICP above 20 mm Hg is considered elevated and
requires intervention. The nurse should notify the healthcare provider immediately. Elevating the HOB
to 30 degrees (not 90) is appropriate, but notification is the priority. IV fluids would increase ICP.
5. Which nursing intervention is most important to prevent increased ICP in a client with a severe head
injury?
A) Keep the head of bed flat
B) Suction the airway every hour
C) Maintain the head and neck in neutral alignment
, D) Cluster all nursing activities to allow for longer rest periods
Correct Answer: Maintain the head and neck in neutral alignment
Rationale: Neck flexion or rotation impedes venous drainage from the brain, increasing ICP. Maintaining
neutral alignment promotes venous outflow, reducing cerebral blood volume and ICP. The head of bed
should be elevated to 30 degrees, and activities should be spaced out (not clustered) to prevent ICP
spikes.
6. A client with increased ICP has a Glasgow Coma Scale (GCS) score of 6. Which intervention would the
nurse anticipate?
A) Ambulate three times daily
B) Continuous electroencephalogram (EEG) monitoring
C) Provide the client with a low-stimulation environment
D) Scheduled doses of IV phenytoin (Dilantin)
Correct Answer: Scheduled doses of IV phenytoin (Dilantin)
Rationale: A GCS of 8 or less indicates severe brain injury. Seizures are common in these patients and
can worsen ICP. Phenytoin is an anticonvulsant often prescribed prophylactically for 7 days post-injury
to prevent seizure activity that could increase ICP.
7. A patient with intracranial pressure (ICP) monitoring has a sustained ICP of 25 mm Hg. Following the
standard protocol, the nurse should prepare to give which IV medication to reduce ICP?
A) Furosemide
B) Mannitol
C) Phenytoin
D) Naloxone
Correct Answer: Mannitol
