1
NUR 265 EXAM 2 2026/2027 | Two Updated Versions |
Adult Health II Validation | 100% Correct Answers | Pass
Guaranteed - A+ Graded
VERSION 1 (V1): Foundational Concepts & Clinical Applications
(Q1-35)
Section 1: Neurological Disorders (Q1-9)
V1 | Q1. A 68-year-old client is brought to the emergency department with sudden
onset right-sided weakness and aphasia. The client's wife states symptoms began 2
hours ago. Vital signs: BP 188/112 mmHg, HR 98, RR 18, SpO₂ 95% on room air.
Which action should the nurse take FIRST?
A. Administer IV tPA immediately
B. Obtain a CT scan of the head without contrast
C. Start an IV antihypertensive to lower BP below 140/90 mmHg
D. Insert a nasogastric tube for medication administration
B. Obtain a CT scan of the head without contrast [CORRECT]
Rationale: Before administering tPA, a non-contrast CT scan is required to rule out
hemorrhagic stroke. The nurse must NEVER give tPA without first confirming the
stroke is ischemic, not hemorrhagic. While BP management is important (goal
<185/110 before tPA), imaging takes priority. NGT insertion is not an immediate
priority.
Correct Answer: B
,2
V1 | Q2. A client receiving IV tPA for acute ischemic stroke develops sudden severe
headache, vomiting, and decreased level of consciousness 45 minutes after infusion
begins. Which is the nurse's PRIORITY action?
A. Slow the tPA infusion rate
B. Stop the tPA infusion immediately and notify the provider
C. Administer an antiemetic and continue the infusion
D. Recheck vital signs in 15 minutes
B. Stop the tPA infusion immediately and notify the provider [CORRECT]
Rationale: These are classic signs of intracranial hemorrhage, the most serious
complication of tPA. The infusion must be stopped immediately. The nurse should
also prepare to obtain a STAT CT scan and follow facility protocol for hemorrhagic
stroke management. Slowing the rate or continuing the infusion could worsen
bleeding.
Correct Answer: B
V1 | Q3. A nurse is caring for a client 24 hours post-hemorrhagic stroke with an ICP
monitor in place. The current ICP reading is 22 mmHg. Which nursing intervention is
MOST appropriate?
A. Position the client in high Fowler's with head midline
B. Administer a bolus of mannitol without provider notification
C. Turn the client to the left side and perform suctioning
D. Encourage the client to perform Valsalva maneuvers
A. Position the client in high Fowler's with head midline [CORRECT]
Rationale: Elevating the head 30-45 degrees with the head in midline position
promotes venous drainage and helps reduce ICP. Mannitol requires a provider order.
Suctioning and Valsalva maneuvers increase ICP and are contraindicated. The nurse
should notify the provider of the elevated ICP but can implement positioning
independently.
Correct Answer: A
,3
V1 | Q4. A client with a known seizure disorder is admitted after experiencing a
generalized tonic-clonic seizure lasting 4 minutes. Which nursing action is the
HIGHEST priority during a subsequent seizure?
A. Insert an oral airway to maintain the airway
B. Restrain the client's extremities to prevent injury
C. Note the time and turn the client to a side-lying position when possible
D. Administer oral lorazepam during the seizure
C. Note the time and turn the client to a side-lying position when possible
[CORRECT]
Rationale: During a seizure, the nurse should follow the "Stay, Safe, Side, Time"
protocol. Never insert anything in the mouth (risk of oral trauma/aspiration) or
restrain (risk of fractures). Oral medications cannot be given during a seizure. Timing
is critical because status epilepticus protocol activates at 5 minutes. Side-lying
position protects the airway from secretions.
Correct Answer: C
V1 | Q5. A client is prescribed phenytoin (Dilantin) for seizure control. Which client
statement indicates the need for additional teaching?
A. "I will take my medication at the same time every day."
B. "I will use a soft toothbrush and floss gently."
C. "I can stop taking this medication when I feel better."
D. "I will have my blood levels checked regularly."
C. "I can stop taking this medication when I feel better." [CORRECT]
Rationale: Antiepileptic medications must NEVER be stopped abruptly as this can
precipitate status epilepticus. Tapering requires provider supervision. The other
statements demonstrate correct understanding: consistent timing maintains
therapeutic levels, phenytoin causes gingival hyperplasia (requires gentle oral care),
and therapeutic drug monitoring is essential.
, 4
Correct Answer: C
V1 | Q6. A client with Parkinson's disease reports increased difficulty with mobility
and frequent falls. The nurse notes the client is taking levodopa/carbidopa (Sinemet).
Which nursing intervention is MOST important?
A. Instruct the client to take the medication with a high-protein meal
B. Assess the client's home for fall hazards and recommend assistive devices
C. Advise the client to stop the medication if dyskinesias develop
D. Encourage the client to increase fluid intake to 4 liters daily
B. Assess the client's home for fall hazards and recommend assistive devices
[CORRECT]
Rationale: Fall prevention is a critical safety intervention for clients with Parkinson's
disease. High-protein meals interfere with levodopa absorption (should be taken on
an empty stomach or with low-protein snack). Dyskinesias should be reported to the
provider, not managed by stopping medication. While hydration is important, 4 liters
is excessive and not specific to Parkinson's.
Correct Answer: B
V1 | Q7. A client with multiple sclerosis is experiencing an acute exacerbation with
increased weakness and difficulty walking. The provider orders high-dose IV
methylprednisolone. The nurse should monitor MOST closely for which adverse
effect?
A. Hyperglycemia
B. Bradycardia
C. Hypokalemia
D. Urinary retention
A. Hyperglycemia [CORRECT]
NUR 265 EXAM 2 2026/2027 | Two Updated Versions |
Adult Health II Validation | 100% Correct Answers | Pass
Guaranteed - A+ Graded
VERSION 1 (V1): Foundational Concepts & Clinical Applications
(Q1-35)
Section 1: Neurological Disorders (Q1-9)
V1 | Q1. A 68-year-old client is brought to the emergency department with sudden
onset right-sided weakness and aphasia. The client's wife states symptoms began 2
hours ago. Vital signs: BP 188/112 mmHg, HR 98, RR 18, SpO₂ 95% on room air.
Which action should the nurse take FIRST?
A. Administer IV tPA immediately
B. Obtain a CT scan of the head without contrast
C. Start an IV antihypertensive to lower BP below 140/90 mmHg
D. Insert a nasogastric tube for medication administration
B. Obtain a CT scan of the head without contrast [CORRECT]
Rationale: Before administering tPA, a non-contrast CT scan is required to rule out
hemorrhagic stroke. The nurse must NEVER give tPA without first confirming the
stroke is ischemic, not hemorrhagic. While BP management is important (goal
<185/110 before tPA), imaging takes priority. NGT insertion is not an immediate
priority.
Correct Answer: B
,2
V1 | Q2. A client receiving IV tPA for acute ischemic stroke develops sudden severe
headache, vomiting, and decreased level of consciousness 45 minutes after infusion
begins. Which is the nurse's PRIORITY action?
A. Slow the tPA infusion rate
B. Stop the tPA infusion immediately and notify the provider
C. Administer an antiemetic and continue the infusion
D. Recheck vital signs in 15 minutes
B. Stop the tPA infusion immediately and notify the provider [CORRECT]
Rationale: These are classic signs of intracranial hemorrhage, the most serious
complication of tPA. The infusion must be stopped immediately. The nurse should
also prepare to obtain a STAT CT scan and follow facility protocol for hemorrhagic
stroke management. Slowing the rate or continuing the infusion could worsen
bleeding.
Correct Answer: B
V1 | Q3. A nurse is caring for a client 24 hours post-hemorrhagic stroke with an ICP
monitor in place. The current ICP reading is 22 mmHg. Which nursing intervention is
MOST appropriate?
A. Position the client in high Fowler's with head midline
B. Administer a bolus of mannitol without provider notification
C. Turn the client to the left side and perform suctioning
D. Encourage the client to perform Valsalva maneuvers
A. Position the client in high Fowler's with head midline [CORRECT]
Rationale: Elevating the head 30-45 degrees with the head in midline position
promotes venous drainage and helps reduce ICP. Mannitol requires a provider order.
Suctioning and Valsalva maneuvers increase ICP and are contraindicated. The nurse
should notify the provider of the elevated ICP but can implement positioning
independently.
Correct Answer: A
,3
V1 | Q4. A client with a known seizure disorder is admitted after experiencing a
generalized tonic-clonic seizure lasting 4 minutes. Which nursing action is the
HIGHEST priority during a subsequent seizure?
A. Insert an oral airway to maintain the airway
B. Restrain the client's extremities to prevent injury
C. Note the time and turn the client to a side-lying position when possible
D. Administer oral lorazepam during the seizure
C. Note the time and turn the client to a side-lying position when possible
[CORRECT]
Rationale: During a seizure, the nurse should follow the "Stay, Safe, Side, Time"
protocol. Never insert anything in the mouth (risk of oral trauma/aspiration) or
restrain (risk of fractures). Oral medications cannot be given during a seizure. Timing
is critical because status epilepticus protocol activates at 5 minutes. Side-lying
position protects the airway from secretions.
Correct Answer: C
V1 | Q5. A client is prescribed phenytoin (Dilantin) for seizure control. Which client
statement indicates the need for additional teaching?
A. "I will take my medication at the same time every day."
B. "I will use a soft toothbrush and floss gently."
C. "I can stop taking this medication when I feel better."
D. "I will have my blood levels checked regularly."
C. "I can stop taking this medication when I feel better." [CORRECT]
Rationale: Antiepileptic medications must NEVER be stopped abruptly as this can
precipitate status epilepticus. Tapering requires provider supervision. The other
statements demonstrate correct understanding: consistent timing maintains
therapeutic levels, phenytoin causes gingival hyperplasia (requires gentle oral care),
and therapeutic drug monitoring is essential.
, 4
Correct Answer: C
V1 | Q6. A client with Parkinson's disease reports increased difficulty with mobility
and frequent falls. The nurse notes the client is taking levodopa/carbidopa (Sinemet).
Which nursing intervention is MOST important?
A. Instruct the client to take the medication with a high-protein meal
B. Assess the client's home for fall hazards and recommend assistive devices
C. Advise the client to stop the medication if dyskinesias develop
D. Encourage the client to increase fluid intake to 4 liters daily
B. Assess the client's home for fall hazards and recommend assistive devices
[CORRECT]
Rationale: Fall prevention is a critical safety intervention for clients with Parkinson's
disease. High-protein meals interfere with levodopa absorption (should be taken on
an empty stomach or with low-protein snack). Dyskinesias should be reported to the
provider, not managed by stopping medication. While hydration is important, 4 liters
is excessive and not specific to Parkinson's.
Correct Answer: B
V1 | Q7. A client with multiple sclerosis is experiencing an acute exacerbation with
increased weakness and difficulty walking. The provider orders high-dose IV
methylprednisolone. The nurse should monitor MOST closely for which adverse
effect?
A. Hyperglycemia
B. Bradycardia
C. Hypokalemia
D. Urinary retention
A. Hyperglycemia [CORRECT]
