NUR2755 Final Exam Fall 2025/2026 – MDC IV Questions and Answers |
Latest Update | 100% Correct | Rasmussen University
1. During the first 24 hours after thrombolytic treatment for an ischemic stroke the nurse’s primary goal
is control which of the following vital signs?
a. Respirations
b. Blood pressure
c. Pulse
d. Temperature
2. A male client, age 69 is being evaluated by a neurologist for signs of muscle rigidity, mask like face (the area
from forehead to chin), and propulsive gait. The nurse interprets these findings as potential indicators of
which neurological disorder?
a. Multiple sclerosis
b. Parkinson’s disease
c. Alzheimer’s disease
d. Epilepsy
3. Which of the following statements by your client’s son indicate the need for further teaching when using
patient-controlled analgesic (PCA)?
a. “I can push the button for my mother if she is too drowsy.”
b. “The medication is flowing through my mother’s intravenous line.”
c. “My mother will push the PCA button when she is experiencing increased pain.”
d. “My mother or I should notify the nurse if her pain is uncontrolled while using the PCA.”
4. A nurse is providing teaching to a class about transient ischemic attack (TIAs). Which information should
the nurse include in the teaching?
a. A TIA can cause cerebral edema
b. A TIA can cause irreversible hemiparesis
c. A TIA can precede an ischemic stroke
d. A TIA can be the result of cerebral bleeding.
TIAs are considered a manifestation of advanced artherosclerotic disease and often precede an
ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak,
transient hemiparesis, vertigo, diplopia, numbness, and weakness.
Acute ischemic strokes often follow warning signs such as a transient ischemic attack (TIA). A TIA is a
temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow. The symptoms of
TIA are easy to ignore or miss, particularly if symptoms resolve by the time the patient reaches the
emergency department (ED). Typically, symptoms of a TIA resolve within 30 to 60 minutes but may last as
long as 24 hours (see the Key Features: Transient Ischemic Attack box).
Common causes of a TIA or stroke are carotid stenosis (hardening and narrowing of the artery, which
decreases blood flow to the brain), often with atherosclerotic plaque buildup, and atrial fibrillation.
Atherosclerotic plaque consists of fat and other substances that adhere to the arterial wall and obstruct or
restrict blood flow.
In addition to the NIH score, patients are often evaluated using the ABCD assessment tool to determine
their risk of having a stroke in the days and weeks after the TIA. The following factors are scored:
• Age greater than or equal to 60 (stroke risk increases with age)
, • Blood pressure (BP) greater than or equal to 140/90 mm Hg (either systolic or diastolic or both)
• Clinical TIA features (unilateral [one-sided] weakness increases stroke risk)
• Duration of symptoms (the longer the TIA symptoms last, the greater the risk of stroke)
5. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure
the safety of the client while in the hospital? (SATA).
a. Maintaining the client on strict bedrest.
b. Place a padded tongue blade at the bedside
c. Keep bed rails up and padded at all times
d. Have suction equipment at the bedside.
e. Ensure that the client has IV access.
f. Permit only clear oral fluids.
• Protect the patient from injury.
• Do not force anything into the patient’s mouth.
• Turn the patient to the side to prevent aspiration and keep the airway clear.
• Remove any objects that might injure the patient.
• Suction oral secretions if possible without force.
• Loosen any restrictive clothing the patient is wearing.
• Do not restrain or try to stop the patient’s movement; guide movements if necessary.
• Record the time the seizure began and ended.
6. A client has been admitted to the neurological department because of seizures of unknown cause. Which
of the following is the priority intervention?
a. Being sure padded side rails are present.
b. Placing the client with one on one nursing service
c. Suggesting that the family monitor the client
d. Placing the client in protective restraints
7. When managing the treatment plan for a client with Guillain Barre syndrome the nurse identifies the client
is at most risk for which body system failure? 834
a. Respiratory
b. Cardiovascular
c. GI
d. CNS
Guillain-Barré syndrome (GBS) is a rare acute inflammatory disorder that affects the axons and/or myelin of
the PNS resulting in ascending muscle weakness or paralysis. As the condition improves, neurologic
assessment may be needed only once each shift. Findings are documented according to agency protocol.
A special spinal cord assessment flow sheet may be used to document sensory and/or motor findings for
the patient with a spinal cord injury. If GBS does not improve, respiratory failure may result in death.
8. A client presents to the emergency department (ED) with the inability to wrinkle her forehead or pucker her lips. She is
afraid she may be having a stroke. After a complete clinical workup is negative for cerebral vascular accident (CVA), the
nurse provides discharge information on which of the following disorders? 829-831
a. Epilepsy
b. Trigeminal neuralgia
, c. Cerebral aneurysm
d. Bell’s Palsy
A peripheral nervous system disorder in which the patient has paralysis of all facial muscles on the affected
side (also called facial paralysis). The patient cannot close his or her eye, wrinkle the forehead, smile,
whistle, or grimace. Tearing may stop or become excessive. The face appears mask like and sags.
Bell’s Palsy: acute paralysis of CN 7 but can also affect CN 5 and 8
● r/o stroke: stroke will last a short duration and have manifestations that are a lot worse and
without pain.
● Clinical manifestations
o Inability to wrinkle forehead
o Facial paralysis
o Drooping of eye and mouth
o Cannot close eyes, smile or whistle
o Ear tinnitus
o Taste changes
● Meds
o Steroids
o Antivirals
9. The client received a preoperative dose of lorazepam 20 minutes ago. Which of the following is the priority
intervention the nurse should take to promote safety for this client?
a. Raised bed rails
b. Monitor respiratory status
c. Take seizure precautions
d. Elevate the head of the bed 30 degrees.
Lorazepam may cause side effects. Call your doctor if any of the following symptoms are severe or do not
go away:
Drowsiness.dizziness.tiredness.weakness.dry mouth.diarrhea.nausea.
10. A client has been injured in a motorcycle accident and is presenting with signs and symptoms of increased
intracranial pressure. What is the most significant sign or symptom of increased intracranial pressure? 867
a. Pupil changes
b. Ipsilateral paralysis
c. Decrease in the level of consciousness
d. Vomiting (late symptoms)
Decreased level of consciousness
, • Disorientation to person, place, and time
• Pupil reaction and eye movements:
• Photophobia (sensitivity to light)
• Nystagmus (involuntary condition in which the eyes make repetitive uncontrolled movements)
11. A graduate nurse is performing discharge teaching for a client newly diagnosed with migraine
headaches. Which statement made by the graduate nurse indicates a correct understanding of this
disorder? 861
a. “Beta-blockers are contraindicated in clients with migraines.”
b. “Increasing stimulating activities during an episode will help resolve the migraines.’ c.
“Aura’s are not a symptom present with migraines.”
d. “Verapamil (THE OPTION WAS “propranolol”) ….“Propranolol is not an abortive migraine medication but
used to manage and prevent migraines”
12. A client has been diagnosed with confused state pathology. The client presents with signs and symptoms
of total or partial loss of the ability to recognize familiar objects or people through sensory stimulation. The
nurse correctly identifies the signs and symptoms as which of the following? 846
a. Aphasia
b. Dysphagia
c. Apraxia
d. Agnosia
Alterations in communication abilities, such as apraxia (inability to use words or objects correctly),
aphasia (inability to speak or understand).
anomia (inability to find words), and agnosia (loss of sensory comprehension, including facial
recognition), are due to dysfunction of the temporal and parietal lobes.
Agnosia:inability to interpret sensations and hence to recognize things, typically as a result of brain
damage.
Aphasia: A language disorder that affects a person's ability to communicate.
It can occur suddenly after a stroke or head injury, or develop slowly from a growing brain tumor or disease.
Apraxia is caused by brain disease or damage. The brain is unable to make and deliver correct movement
instructions to the body.
13. A nurse is assessing a client in postoperative recovery. The client complains of the following
symptoms. Which of the following is abnormal and should be reported immediately? 172
Latest Update | 100% Correct | Rasmussen University
1. During the first 24 hours after thrombolytic treatment for an ischemic stroke the nurse’s primary goal
is control which of the following vital signs?
a. Respirations
b. Blood pressure
c. Pulse
d. Temperature
2. A male client, age 69 is being evaluated by a neurologist for signs of muscle rigidity, mask like face (the area
from forehead to chin), and propulsive gait. The nurse interprets these findings as potential indicators of
which neurological disorder?
a. Multiple sclerosis
b. Parkinson’s disease
c. Alzheimer’s disease
d. Epilepsy
3. Which of the following statements by your client’s son indicate the need for further teaching when using
patient-controlled analgesic (PCA)?
a. “I can push the button for my mother if she is too drowsy.”
b. “The medication is flowing through my mother’s intravenous line.”
c. “My mother will push the PCA button when she is experiencing increased pain.”
d. “My mother or I should notify the nurse if her pain is uncontrolled while using the PCA.”
4. A nurse is providing teaching to a class about transient ischemic attack (TIAs). Which information should
the nurse include in the teaching?
a. A TIA can cause cerebral edema
b. A TIA can cause irreversible hemiparesis
c. A TIA can precede an ischemic stroke
d. A TIA can be the result of cerebral bleeding.
TIAs are considered a manifestation of advanced artherosclerotic disease and often precede an
ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak,
transient hemiparesis, vertigo, diplopia, numbness, and weakness.
Acute ischemic strokes often follow warning signs such as a transient ischemic attack (TIA). A TIA is a
temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow. The symptoms of
TIA are easy to ignore or miss, particularly if symptoms resolve by the time the patient reaches the
emergency department (ED). Typically, symptoms of a TIA resolve within 30 to 60 minutes but may last as
long as 24 hours (see the Key Features: Transient Ischemic Attack box).
Common causes of a TIA or stroke are carotid stenosis (hardening and narrowing of the artery, which
decreases blood flow to the brain), often with atherosclerotic plaque buildup, and atrial fibrillation.
Atherosclerotic plaque consists of fat and other substances that adhere to the arterial wall and obstruct or
restrict blood flow.
In addition to the NIH score, patients are often evaluated using the ABCD assessment tool to determine
their risk of having a stroke in the days and weeks after the TIA. The following factors are scored:
• Age greater than or equal to 60 (stroke risk increases with age)
, • Blood pressure (BP) greater than or equal to 140/90 mm Hg (either systolic or diastolic or both)
• Clinical TIA features (unilateral [one-sided] weakness increases stroke risk)
• Duration of symptoms (the longer the TIA symptoms last, the greater the risk of stroke)
5. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure
the safety of the client while in the hospital? (SATA).
a. Maintaining the client on strict bedrest.
b. Place a padded tongue blade at the bedside
c. Keep bed rails up and padded at all times
d. Have suction equipment at the bedside.
e. Ensure that the client has IV access.
f. Permit only clear oral fluids.
• Protect the patient from injury.
• Do not force anything into the patient’s mouth.
• Turn the patient to the side to prevent aspiration and keep the airway clear.
• Remove any objects that might injure the patient.
• Suction oral secretions if possible without force.
• Loosen any restrictive clothing the patient is wearing.
• Do not restrain or try to stop the patient’s movement; guide movements if necessary.
• Record the time the seizure began and ended.
6. A client has been admitted to the neurological department because of seizures of unknown cause. Which
of the following is the priority intervention?
a. Being sure padded side rails are present.
b. Placing the client with one on one nursing service
c. Suggesting that the family monitor the client
d. Placing the client in protective restraints
7. When managing the treatment plan for a client with Guillain Barre syndrome the nurse identifies the client
is at most risk for which body system failure? 834
a. Respiratory
b. Cardiovascular
c. GI
d. CNS
Guillain-Barré syndrome (GBS) is a rare acute inflammatory disorder that affects the axons and/or myelin of
the PNS resulting in ascending muscle weakness or paralysis. As the condition improves, neurologic
assessment may be needed only once each shift. Findings are documented according to agency protocol.
A special spinal cord assessment flow sheet may be used to document sensory and/or motor findings for
the patient with a spinal cord injury. If GBS does not improve, respiratory failure may result in death.
8. A client presents to the emergency department (ED) with the inability to wrinkle her forehead or pucker her lips. She is
afraid she may be having a stroke. After a complete clinical workup is negative for cerebral vascular accident (CVA), the
nurse provides discharge information on which of the following disorders? 829-831
a. Epilepsy
b. Trigeminal neuralgia
, c. Cerebral aneurysm
d. Bell’s Palsy
A peripheral nervous system disorder in which the patient has paralysis of all facial muscles on the affected
side (also called facial paralysis). The patient cannot close his or her eye, wrinkle the forehead, smile,
whistle, or grimace. Tearing may stop or become excessive. The face appears mask like and sags.
Bell’s Palsy: acute paralysis of CN 7 but can also affect CN 5 and 8
● r/o stroke: stroke will last a short duration and have manifestations that are a lot worse and
without pain.
● Clinical manifestations
o Inability to wrinkle forehead
o Facial paralysis
o Drooping of eye and mouth
o Cannot close eyes, smile or whistle
o Ear tinnitus
o Taste changes
● Meds
o Steroids
o Antivirals
9. The client received a preoperative dose of lorazepam 20 minutes ago. Which of the following is the priority
intervention the nurse should take to promote safety for this client?
a. Raised bed rails
b. Monitor respiratory status
c. Take seizure precautions
d. Elevate the head of the bed 30 degrees.
Lorazepam may cause side effects. Call your doctor if any of the following symptoms are severe or do not
go away:
Drowsiness.dizziness.tiredness.weakness.dry mouth.diarrhea.nausea.
10. A client has been injured in a motorcycle accident and is presenting with signs and symptoms of increased
intracranial pressure. What is the most significant sign or symptom of increased intracranial pressure? 867
a. Pupil changes
b. Ipsilateral paralysis
c. Decrease in the level of consciousness
d. Vomiting (late symptoms)
Decreased level of consciousness
, • Disorientation to person, place, and time
• Pupil reaction and eye movements:
• Photophobia (sensitivity to light)
• Nystagmus (involuntary condition in which the eyes make repetitive uncontrolled movements)
11. A graduate nurse is performing discharge teaching for a client newly diagnosed with migraine
headaches. Which statement made by the graduate nurse indicates a correct understanding of this
disorder? 861
a. “Beta-blockers are contraindicated in clients with migraines.”
b. “Increasing stimulating activities during an episode will help resolve the migraines.’ c.
“Aura’s are not a symptom present with migraines.”
d. “Verapamil (THE OPTION WAS “propranolol”) ….“Propranolol is not an abortive migraine medication but
used to manage and prevent migraines”
12. A client has been diagnosed with confused state pathology. The client presents with signs and symptoms
of total or partial loss of the ability to recognize familiar objects or people through sensory stimulation. The
nurse correctly identifies the signs and symptoms as which of the following? 846
a. Aphasia
b. Dysphagia
c. Apraxia
d. Agnosia
Alterations in communication abilities, such as apraxia (inability to use words or objects correctly),
aphasia (inability to speak or understand).
anomia (inability to find words), and agnosia (loss of sensory comprehension, including facial
recognition), are due to dysfunction of the temporal and parietal lobes.
Agnosia:inability to interpret sensations and hence to recognize things, typically as a result of brain
damage.
Aphasia: A language disorder that affects a person's ability to communicate.
It can occur suddenly after a stroke or head injury, or develop slowly from a growing brain tumor or disease.
Apraxia is caused by brain disease or damage. The brain is unable to make and deliver correct movement
instructions to the body.
13. A nurse is assessing a client in postoperative recovery. The client complains of the following
symptoms. Which of the following is abnormal and should be reported immediately? 172
