NUR417 Care of Adult II Exam 1, 2, 3 & Final Exam | Latest
Update 2026/2027 | 200 Questions and Verified Answers |
Concordia University Complete Q&A Guide | A+ Graded
1. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be
included in the plan of care?
A. Avoid the use of anticoagulant medications.
B. Measure the patient's urinary output every hour.
C. Provide passive range of motion for all extremities.
D. Position the patient supine with head flat at all times.
Answer: B. Monitoring urine output helps determine whether cardiac output has improved and helps
monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to
30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the
extremity with the balloon insertion site to prevent displacement.
2. Which hemodynamic parameter best reflects the effectiveness of drugs given to reduce a patient's
left ventricular afterload?
A. Mean arterial pressure (MAP)
B. Systemic vascular resistance (SVR)
C. Pulmonary vascular resistance (PVR)
D. Pulmonary artery wedge pressure (PAWP)
Answer: B. SVR reflects resistance to ventricular ejection, or afterload. MAP reflects perfusion pressure,
PVR reflects right ventricular afterload, and PAWP reflects left ventricular preload.
,3. A patient with a head injury opens eyes to verbal stimulation, curses when stimulated, and does not
respond to verbal command to move but attempts to remove a painful stimulus. The nurse records the
Glasgow Coma Scale score as:
A. 9
B. 11
C. 13
D. 15
Answer: B. The patient scores 3 for eye opening (to verbal stimulation = 3), 3 for best verbal response
(inappropriate words/curses = 3), and 5 for best motor response (localizes to pain = 5), totaling 11.
4. The nurse is providing care for a patient admitted with a head injury requiring regular neurologic
assessment. Which assessments are components of the Glasgow Coma Scale (GCS)? (Select all that
apply)
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
Answer: B, D, E. The three dimensions of the GCS are eye opening, best verbal response, and best motor
response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
5. When caring for a patient who has had a head injury, which assessment information requires the
most rapid action by the nurse?
A. The patient is more difficult to arouse.
,B. The patient's pulse is slightly irregular.
C. The patient's blood pressure increases from 120/54 to 136/62 mm Hg.
D. The patient complains of a headache at pain level 5 on a 10point scale.
Answer: A. Change in level of consciousness (LOC) is one of the most sensitive indicators of increased
intracranial pressure (ICP) and requires immediate action. A decrease in LOC occurs before changes in
vital signs, ocular signs, or projectile vomiting.
6. Which patient should the nurse assess first on a clinical unit?
A. Patient with a skull fracture whose nose is bleeding
B. Older patient with a stroke who is confused and whose daughter is present
C. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 010 scale
D. Patient who had a craniotomy for a brain tumor who is 3 days postoperative and has continued
vomiting
Answer: C. The patient with meningitis should be seen first; patients with meningitis must be observed
closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and
increased CSF volume. Sudden change in LOC or behavior change along with severe headache indicates
potential neurologic deterioration.
7. The nurse suspects elder abuse in an older adult patient. Which action is appropriate?
A. Collect proof of abuse before notifying authorities.
B. Confront the caretakers about the suspicion of abuse.
C. Notify the authorities of the suspected elder abuse.
D. Report the abuse only if the older adult gives permission.
, Answer: C. The nurse is a mandatory reporter of elder abuse and should notify authorities of suspected
abuse. The nurse does not need proof before calling, should not confront caretakers, and does not need
permission from the elder.
8. A nurse suspects physical abuse in a child. What is the primary legal responsibility?
A. Document assessment thoroughly and accurately.
B. Report the abuse to local authorities.
C. Refer the family to support groups.
D. Assist the family in identifying resources and support systems.
Answer: B. The nurse must report suspicions to local authorities for investigation. The law makes it
mandatory to report suspected child abuse. Other options are important but not the priority.
9. Which action should the nurse plan to prevent aspiration in a highrisk patient?
A. Turn and reposition an immobile patient at least every 2 hours.
B. Place a patient with altered consciousness in a sidelying position.
C. Insert a nasogastric tube for feeding a patient with high calorie needs.
D. Monitor respiratory symptoms in a patient who is immunosuppressed.
Answer: B. With loss of consciousness, gag and cough reflexes are depressed, and aspiration is more
likely. Risk for aspiration is decreased when patients with decreased LOC are placed in a sidelying or
upright position.
10. A patient is admitted with an open stab wound to the left chest. What action should the nurse take?
Update 2026/2027 | 200 Questions and Verified Answers |
Concordia University Complete Q&A Guide | A+ Graded
1. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be
included in the plan of care?
A. Avoid the use of anticoagulant medications.
B. Measure the patient's urinary output every hour.
C. Provide passive range of motion for all extremities.
D. Position the patient supine with head flat at all times.
Answer: B. Monitoring urine output helps determine whether cardiac output has improved and helps
monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to
30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the
extremity with the balloon insertion site to prevent displacement.
2. Which hemodynamic parameter best reflects the effectiveness of drugs given to reduce a patient's
left ventricular afterload?
A. Mean arterial pressure (MAP)
B. Systemic vascular resistance (SVR)
C. Pulmonary vascular resistance (PVR)
D. Pulmonary artery wedge pressure (PAWP)
Answer: B. SVR reflects resistance to ventricular ejection, or afterload. MAP reflects perfusion pressure,
PVR reflects right ventricular afterload, and PAWP reflects left ventricular preload.
,3. A patient with a head injury opens eyes to verbal stimulation, curses when stimulated, and does not
respond to verbal command to move but attempts to remove a painful stimulus. The nurse records the
Glasgow Coma Scale score as:
A. 9
B. 11
C. 13
D. 15
Answer: B. The patient scores 3 for eye opening (to verbal stimulation = 3), 3 for best verbal response
(inappropriate words/curses = 3), and 5 for best motor response (localizes to pain = 5), totaling 11.
4. The nurse is providing care for a patient admitted with a head injury requiring regular neurologic
assessment. Which assessments are components of the Glasgow Coma Scale (GCS)? (Select all that
apply)
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
Answer: B, D, E. The three dimensions of the GCS are eye opening, best verbal response, and best motor
response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
5. When caring for a patient who has had a head injury, which assessment information requires the
most rapid action by the nurse?
A. The patient is more difficult to arouse.
,B. The patient's pulse is slightly irregular.
C. The patient's blood pressure increases from 120/54 to 136/62 mm Hg.
D. The patient complains of a headache at pain level 5 on a 10point scale.
Answer: A. Change in level of consciousness (LOC) is one of the most sensitive indicators of increased
intracranial pressure (ICP) and requires immediate action. A decrease in LOC occurs before changes in
vital signs, ocular signs, or projectile vomiting.
6. Which patient should the nurse assess first on a clinical unit?
A. Patient with a skull fracture whose nose is bleeding
B. Older patient with a stroke who is confused and whose daughter is present
C. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 010 scale
D. Patient who had a craniotomy for a brain tumor who is 3 days postoperative and has continued
vomiting
Answer: C. The patient with meningitis should be seen first; patients with meningitis must be observed
closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and
increased CSF volume. Sudden change in LOC or behavior change along with severe headache indicates
potential neurologic deterioration.
7. The nurse suspects elder abuse in an older adult patient. Which action is appropriate?
A. Collect proof of abuse before notifying authorities.
B. Confront the caretakers about the suspicion of abuse.
C. Notify the authorities of the suspected elder abuse.
D. Report the abuse only if the older adult gives permission.
, Answer: C. The nurse is a mandatory reporter of elder abuse and should notify authorities of suspected
abuse. The nurse does not need proof before calling, should not confront caretakers, and does not need
permission from the elder.
8. A nurse suspects physical abuse in a child. What is the primary legal responsibility?
A. Document assessment thoroughly and accurately.
B. Report the abuse to local authorities.
C. Refer the family to support groups.
D. Assist the family in identifying resources and support systems.
Answer: B. The nurse must report suspicions to local authorities for investigation. The law makes it
mandatory to report suspected child abuse. Other options are important but not the priority.
9. Which action should the nurse plan to prevent aspiration in a highrisk patient?
A. Turn and reposition an immobile patient at least every 2 hours.
B. Place a patient with altered consciousness in a sidelying position.
C. Insert a nasogastric tube for feeding a patient with high calorie needs.
D. Monitor respiratory symptoms in a patient who is immunosuppressed.
Answer: B. With loss of consciousness, gag and cough reflexes are depressed, and aspiration is more
likely. Risk for aspiration is decreased when patients with decreased LOC are placed in a sidelying or
upright position.
10. A patient is admitted with an open stab wound to the left chest. What action should the nurse take?
