Adult Health Nursing II – Comprehensive
Exam Questions, Answers & Rationales
Question 1:
A client with acute ischemic stroke suddenly develops worsening level of
consciousness, vomiting, and a new unequal pupil size. Which action should the
nurse take first?
A. Administer the prescribed oral antihypertensive
B. Place the client flat and encourage fluids
C. Notify the rapid response team and maintain the airway
D. Reassess the client in 30 minutes
Correct Answer: C. Notify the rapid response team and maintain the airway
Rationale: Worsening consciousness, vomiting, and unequal pupils may indicate
increased intracranial pressure or cerebral herniation. This is an emergency
requiring immediate airway support and escalation of care. Delaying intervention
for routine medications or reassessment could result in rapid neurological
deterioration.
Question 2:
A client with a traumatic brain injury has a Glasgow Coma Scale score that
decreases from 13 to 9. Which finding is most concerning?
A. Heart rate of 88/min
B. Increasing level of consciousness
,C. New-onset unilateral weakness
D. Temperature of 37.1°C
Correct Answer: C. New-onset unilateral weakness
Rationale: A declining Glasgow Coma Scale score and new focal neurological
deficits suggest worsening intracranial pathology. Unilateral weakness can indicate
expanding hemorrhage, cerebral edema, or increased intracranial pressure. The
nurse should immediately report the change and prepare for urgent neurological
evaluation.
Question 3:
A client with increased intracranial pressure is being positioned by the nurse.
Which intervention is appropriate?
A. Keep the neck flexed
B. Elevate the head of the bed approximately 30 degrees
C. Place the client in Trendelenburg position
D. Encourage frequent hip flexion
Correct Answer: B. Elevate the head of the bed approximately 30 degrees
Rationale: Elevating the head of the bed promotes venous drainage from the brain
and can help reduce intracranial pressure. The head and neck should remain
aligned, while excessive hip flexion, neck flexion, and positions that impair venous
return should be avoided.
Question 4:
A client with a spinal cord injury at T6 suddenly reports a severe headache and has
a blood pressure of 210/110 mm Hg. Which action should the nurse take first?
,A. Place the client in a supine position
B. Raise the head of the bed
C. Administer oral fluids
D. Apply a warm blanket
Correct Answer: B. Raise the head of the bed
Rationale: The client is experiencing autonomic dysreflexia, a potentially life-
threatening response to an irritating stimulus below the level of injury. Sitting the
client upright helps lower blood pressure. The nurse should then identify and
remove the triggering stimulus, commonly bladder or bowel distention.
Question 5:
A client with Parkinson disease has difficulty initiating movement when
approaching a doorway. Which intervention should the nurse recommend?
A. Tell the client to walk faster
B. Encourage deliberate stepping over a visual target
C. Keep both feet together before walking
D. Discourage the use of assistive devices
Correct Answer: B. Encourage deliberate stepping over a visual target
Rationale: Clients with Parkinson disease may experience freezing, particularly
when turning or approaching doorways. Visual cues, such as stepping over a line or
imagining a target, can help initiate movement. The nurse should allow adequate
time and reduce pressure to move quickly.
, Question 6:
A client with myasthenia gravis develops increasing difficulty swallowing and
speaking near the end of the day. Which assessment is the priority?
A. Bowel sounds
B. Respiratory effort and vital capacity
C. Urine specific gravity
D. Peripheral pulses
Correct Answer: B. Respiratory effort and vital capacity
Rationale: Myasthenia gravis can cause progressive skeletal muscle weakness,
including respiratory muscles. Dysphagia and dysarthria may precede respiratory
failure. The nurse should closely assess respiratory function, including vital
capacity when available, because respiratory compromise requires immediate
intervention.
Question 7:
A client with multiple sclerosis reports worsening weakness after exercising in a
hot environment. Which explanation by the nurse is most appropriate?
A. Heat can temporarily worsen neurological symptoms
B. Exercise permanently destroys myelin
C. Heat causes an increase in cerebrospinal fluid
D. The symptoms indicate bacterial infection
Correct Answer: A. Heat can temporarily worsen neurological symptoms
Rationale: Increased body temperature can temporarily worsen neurological
symptoms in multiple sclerosis, a phenomenon known as Uhthoff phenomenon.
Exam Questions, Answers & Rationales
Question 1:
A client with acute ischemic stroke suddenly develops worsening level of
consciousness, vomiting, and a new unequal pupil size. Which action should the
nurse take first?
A. Administer the prescribed oral antihypertensive
B. Place the client flat and encourage fluids
C. Notify the rapid response team and maintain the airway
D. Reassess the client in 30 minutes
Correct Answer: C. Notify the rapid response team and maintain the airway
Rationale: Worsening consciousness, vomiting, and unequal pupils may indicate
increased intracranial pressure or cerebral herniation. This is an emergency
requiring immediate airway support and escalation of care. Delaying intervention
for routine medications or reassessment could result in rapid neurological
deterioration.
Question 2:
A client with a traumatic brain injury has a Glasgow Coma Scale score that
decreases from 13 to 9. Which finding is most concerning?
A. Heart rate of 88/min
B. Increasing level of consciousness
,C. New-onset unilateral weakness
D. Temperature of 37.1°C
Correct Answer: C. New-onset unilateral weakness
Rationale: A declining Glasgow Coma Scale score and new focal neurological
deficits suggest worsening intracranial pathology. Unilateral weakness can indicate
expanding hemorrhage, cerebral edema, or increased intracranial pressure. The
nurse should immediately report the change and prepare for urgent neurological
evaluation.
Question 3:
A client with increased intracranial pressure is being positioned by the nurse.
Which intervention is appropriate?
A. Keep the neck flexed
B. Elevate the head of the bed approximately 30 degrees
C. Place the client in Trendelenburg position
D. Encourage frequent hip flexion
Correct Answer: B. Elevate the head of the bed approximately 30 degrees
Rationale: Elevating the head of the bed promotes venous drainage from the brain
and can help reduce intracranial pressure. The head and neck should remain
aligned, while excessive hip flexion, neck flexion, and positions that impair venous
return should be avoided.
Question 4:
A client with a spinal cord injury at T6 suddenly reports a severe headache and has
a blood pressure of 210/110 mm Hg. Which action should the nurse take first?
,A. Place the client in a supine position
B. Raise the head of the bed
C. Administer oral fluids
D. Apply a warm blanket
Correct Answer: B. Raise the head of the bed
Rationale: The client is experiencing autonomic dysreflexia, a potentially life-
threatening response to an irritating stimulus below the level of injury. Sitting the
client upright helps lower blood pressure. The nurse should then identify and
remove the triggering stimulus, commonly bladder or bowel distention.
Question 5:
A client with Parkinson disease has difficulty initiating movement when
approaching a doorway. Which intervention should the nurse recommend?
A. Tell the client to walk faster
B. Encourage deliberate stepping over a visual target
C. Keep both feet together before walking
D. Discourage the use of assistive devices
Correct Answer: B. Encourage deliberate stepping over a visual target
Rationale: Clients with Parkinson disease may experience freezing, particularly
when turning or approaching doorways. Visual cues, such as stepping over a line or
imagining a target, can help initiate movement. The nurse should allow adequate
time and reduce pressure to move quickly.
, Question 6:
A client with myasthenia gravis develops increasing difficulty swallowing and
speaking near the end of the day. Which assessment is the priority?
A. Bowel sounds
B. Respiratory effort and vital capacity
C. Urine specific gravity
D. Peripheral pulses
Correct Answer: B. Respiratory effort and vital capacity
Rationale: Myasthenia gravis can cause progressive skeletal muscle weakness,
including respiratory muscles. Dysphagia and dysarthria may precede respiratory
failure. The nurse should closely assess respiratory function, including vital
capacity when available, because respiratory compromise requires immediate
intervention.
Question 7:
A client with multiple sclerosis reports worsening weakness after exercising in a
hot environment. Which explanation by the nurse is most appropriate?
A. Heat can temporarily worsen neurological symptoms
B. Exercise permanently destroys myelin
C. Heat causes an increase in cerebrospinal fluid
D. The symptoms indicate bacterial infection
Correct Answer: A. Heat can temporarily worsen neurological symptoms
Rationale: Increased body temperature can temporarily worsen neurological
symptoms in multiple sclerosis, a phenomenon known as Uhthoff phenomenon.
