NURS 480/ NURS480 – Advanced Medical Surgical
Health Nursing | WCU | 2026–2027 | EXAM 3 Content
with Verified Questions and Answers
The nurse needs to perform a neuro assessment to determine pupillary response, ask if a
headache is present, take vital signs, and contact the health care provider. The client may be
exhibiting subtle signs of increased intracranial pressure which includes restlessness,
agitation, headache, and pupil changes.
A client is taking felbamate (Felbatol) for seizures and displays symptoms of
pancytopenia based on which assessment findings? (Select all that apply)
1. Sore throat
2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - ANS ✓1. Sore throat
2. Epistaxis
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like
feeling, and may exhibit increased bleeding with reduced platelet count (epitaxis). Skin rash
may not indicate pancytopenia. Gingival hyperplasia is an adverse affect of anticonvulsants
like phenytoin, but is not a symptom of pancytopenia. Pancytopenia affects red cells, white
,cells, and platelets and represents bone marrow's response to on-hematologic conditions such
as drugs.
A client is being discharged with a new prescription of phenytoin sodium (dilantin).
Which instruction by the nurse is most important to include?
1. If stopped abruptly, status epilepticus may occur.
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood.
3. Take the medication with antacids to reduce gastric upset.
4. Dilantin will not affect contraceptive effectiveness. - ANS ✓1. If stopped abruptly,
status epilepticus may occur.
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as
doing so may present a risk for return of life-threatening seizure activity. Sulfonamides will
increase phenytoin levels. The drug should not be taken with antacids and will lower
phenytoin absorption. Clients on contraceptive hormone therapy may need to use alternative
forms of non-hormonal contraceptives while on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings
through a nasogastric tube. Which action takes priority when managing enteral feedings?
1. Weigh the client daily at the same time.
2. Make sure sterile water and sterile gavage system is changed every 24 hours.
3. Keep the client in semi-fowlers position.
, 4. Keep the formula warm by setting in hot water 30 minutes prior to administration. -
ANS ✓3. Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric feedings to
prevent aspiration. While daily weights may be important, protecting the airway and lungs
from aspiration is more important. Having sterile water and supplies are not necessary since
the management is with clean not sterile procedure. The formula should be room temperature
and should never be heated prior to administration.
The nurse will collaborate with the interdisciplinary team on communication assist with
a client with expressive aphasia. The team decided on which intervention to help with
communication?
1. Make sure all staff know to speak slowly and in short sentences.
2. Make sure all staff speak loudly for the client to hear.
3. Make sure all staff write on a clipboard for the client to read communication.
4. Make sure all staff assist the client with use of a picture board which is client driven.
- ANS ✓4. Make sure all staff assist the client with use of a picture board which is client
driven.
Expressive aphasia clients may understand what is heard or written, but they may not
be able to verbally communicate their needs. A picture or communication board helps the
client as the client can point to or direct others towards objects on the board for wants and
needs. Speaking loudly or slowly is not therapeutic for communication and may diminish the
client's dignity. Having staff to be the only ones to write implies one-way communication that
, is staff-driven and not client-need driven. The focus is client-centered care and the client
should be encouraged to express needs and wants through therapeutic means.
The nurse is caring for a client with increased intracranial pressure. Which respiratory
pattern changes will signal increased intracranial pressure?
1. Rapid, shallow respirations.
2. Nasal flaring.
3. Slow, irregular respirations.
4. Sudden increase in respiratory secretions - ANS ✓3. Slow, irregular respirations.
Respiratory changes associated with increased intracranial pressure are the result of
deterioration of neural control of respirations, which is controlled by the brain stem.
Deterioration and pressure produce irregular respiratory patterns. Nasal flaring and rapid
shallow respirations are a sign of respiratory distress which may not have root causes because
of neurological changes.
The emergency department nurse receives a client with an ischemic stroke, and
prepares to administer tissue plasminogen activator (t-PA). What question should the nurse
ask first before administering the t-PA?
1. Ask the client which arm or leg is affected.
2. Ask the client if speech was slurred.
3. The nurse will ask time of onset of stroke.
Health Nursing | WCU | 2026–2027 | EXAM 3 Content
with Verified Questions and Answers
The nurse needs to perform a neuro assessment to determine pupillary response, ask if a
headache is present, take vital signs, and contact the health care provider. The client may be
exhibiting subtle signs of increased intracranial pressure which includes restlessness,
agitation, headache, and pupil changes.
A client is taking felbamate (Felbatol) for seizures and displays symptoms of
pancytopenia based on which assessment findings? (Select all that apply)
1. Sore throat
2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - ANS ✓1. Sore throat
2. Epistaxis
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like
feeling, and may exhibit increased bleeding with reduced platelet count (epitaxis). Skin rash
may not indicate pancytopenia. Gingival hyperplasia is an adverse affect of anticonvulsants
like phenytoin, but is not a symptom of pancytopenia. Pancytopenia affects red cells, white
,cells, and platelets and represents bone marrow's response to on-hematologic conditions such
as drugs.
A client is being discharged with a new prescription of phenytoin sodium (dilantin).
Which instruction by the nurse is most important to include?
1. If stopped abruptly, status epilepticus may occur.
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood.
3. Take the medication with antacids to reduce gastric upset.
4. Dilantin will not affect contraceptive effectiveness. - ANS ✓1. If stopped abruptly,
status epilepticus may occur.
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as
doing so may present a risk for return of life-threatening seizure activity. Sulfonamides will
increase phenytoin levels. The drug should not be taken with antacids and will lower
phenytoin absorption. Clients on contraceptive hormone therapy may need to use alternative
forms of non-hormonal contraceptives while on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings
through a nasogastric tube. Which action takes priority when managing enteral feedings?
1. Weigh the client daily at the same time.
2. Make sure sterile water and sterile gavage system is changed every 24 hours.
3. Keep the client in semi-fowlers position.
, 4. Keep the formula warm by setting in hot water 30 minutes prior to administration. -
ANS ✓3. Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric feedings to
prevent aspiration. While daily weights may be important, protecting the airway and lungs
from aspiration is more important. Having sterile water and supplies are not necessary since
the management is with clean not sterile procedure. The formula should be room temperature
and should never be heated prior to administration.
The nurse will collaborate with the interdisciplinary team on communication assist with
a client with expressive aphasia. The team decided on which intervention to help with
communication?
1. Make sure all staff know to speak slowly and in short sentences.
2. Make sure all staff speak loudly for the client to hear.
3. Make sure all staff write on a clipboard for the client to read communication.
4. Make sure all staff assist the client with use of a picture board which is client driven.
- ANS ✓4. Make sure all staff assist the client with use of a picture board which is client
driven.
Expressive aphasia clients may understand what is heard or written, but they may not
be able to verbally communicate their needs. A picture or communication board helps the
client as the client can point to or direct others towards objects on the board for wants and
needs. Speaking loudly or slowly is not therapeutic for communication and may diminish the
client's dignity. Having staff to be the only ones to write implies one-way communication that
, is staff-driven and not client-need driven. The focus is client-centered care and the client
should be encouraged to express needs and wants through therapeutic means.
The nurse is caring for a client with increased intracranial pressure. Which respiratory
pattern changes will signal increased intracranial pressure?
1. Rapid, shallow respirations.
2. Nasal flaring.
3. Slow, irregular respirations.
4. Sudden increase in respiratory secretions - ANS ✓3. Slow, irregular respirations.
Respiratory changes associated with increased intracranial pressure are the result of
deterioration of neural control of respirations, which is controlled by the brain stem.
Deterioration and pressure produce irregular respiratory patterns. Nasal flaring and rapid
shallow respirations are a sign of respiratory distress which may not have root causes because
of neurological changes.
The emergency department nurse receives a client with an ischemic stroke, and
prepares to administer tissue plasminogen activator (t-PA). What question should the nurse
ask first before administering the t-PA?
1. Ask the client which arm or leg is affected.
2. Ask the client if speech was slurred.
3. The nurse will ask time of onset of stroke.
