NR 325 Adult Health II (Med-Surg 2) Final
ACTUAL EXAM TEST BANK 200
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED
A+||NEWEST VERSION 2026/2027
A client is scheduled for a diagnostic procedure to evaluate cerebral blood flow and identify a
possible aneurysm. A catheter is inserted into the femoral artery, contrast dye is injected, and X-
ray images are obtained. What procedure is being performed?
Correct Answer:
Cerebral angiography
Expert Rationale:
Cerebral angiography is an invasive imaging procedure used to assess blood flow within the
brain, identify aneurysms, and evaluate tumor vascularity. A catheter is inserted into an artery
(commonly the femoral or carotid), contrast dye is injected, and X-rays are taken. After the
procedure, pressure or a closure device is applied to prevent bleeding. Clients often report a
warm sensation and metallic taste during dye injection.
Why other options are incorrect:
• CT scan: Noninvasive imaging, does not involve arterial catheterization.
• MRI: Uses magnetic fields, not contrast injection via catheter.
• EEG: Measures electrical activity, not blood flow.
DIF: Analysis
REF: Neurological Diagnostics
OBJ: Identify cerebral angiography procedure and purpose
TOP: Diagnostic Procedures
A client undergoing a cerebral angiography reports a sudden warm sensation in the face and a
metallic taste during the procedure. What is the nurse’s best interpretation?
,Correct Answer:
Normal reaction to contrast dye injection
Expert Rationale:
During cerebral angiography, injection of contrast dye commonly causes a transient warm
sensation and metallic taste. These are expected findings and do not indicate complications. The
nurse should reassure the client while continuing to monitor vital signs.
Why other options are incorrect:
• Allergic reaction: Would include rash, dyspnea, or hypotension.
• Stroke: Would present with neurological deficits.
• Hemorrhage: Would cause pain or swelling at insertion site.
DIF: Application
REF: Neurological Diagnostics
OBJ: Recognize normal findings during angiography
TOP: Nursing Care
A client with a Glasgow Coma Scale (GCS) score of 7 is admitted after a head injury. Which
intervention is most appropriate?
Correct Answer:
Initiate intracranial pressure (ICP) monitoring
Expert Rationale:
Clients with a GCS score of 8 or lower are candidates for ICP monitoring. Elevated ICP can
reduce cerebral perfusion and lead to brain death if untreated. Monitoring allows early
detection and management of increased pressure.
Why other options are incorrect:
• Routine observation only: Insufficient for severe impairment.
• Immediate discharge: Unsafe due to critical condition.
• EEG monitoring: Does not measure pressure changes.
DIF: Analysis
REF: Neurological Diagnostics
OBJ: Identify indications for ICP monitoring
TOP: Critical Care
A client presents with severe headache, dilated pupils, irregular respirations, and abnormal
posturing. What condition should the nurse suspect?
Correct Answer:
Increased intracranial pressure
,Expert Rationale:
Signs of increased ICP include severe headache, pupillary changes, altered breathing patterns,
and motor deterioration such as abnormal posturing. Elevated ICP compromises cerebral
circulation and requires urgent intervention.
Why other options are incorrect:
• Hypoglycemia: Causes confusion but not posturing.
• Seizure disorder: Symptoms are episodic, not persistent.
• Meningitis: Includes fever and neck stiffness primarily.
DIF: Analysis
REF: Neurological Diagnostics
OBJ: Recognize signs of increased ICP
TOP: Pathophysiology
A client undergoes a lumbar puncture. Which post-procedure intervention is most important?
Correct Answer:
Keep the client lying flat for several hours
Expert Rationale:
After a lumbar puncture, the client should remain flat to reduce the risk of cerebrospinal fluid
(CSF) leakage, which can cause severe headaches. Monitoring the puncture site is also essential
to ensure proper clotting.
Why other options are incorrect:
• Immediate ambulation: Increases risk of CSF leak.
• Elevating the head: Can worsen headache.
• Restricting fluids: Hydration actually helps recovery.
DIF: Application
REF: Lumbar Puncture
OBJ: Identify post-procedure care
TOP: Nursing Interventions
A client develops a severe headache after a lumbar puncture that does not resolve with rest.
What is the most appropriate intervention?
Correct Answer:
Prepare for an epidural blood patch
Expert Rationale:
Persistent headache after lumbar puncture is usually due to CSF leakage. An epidural blood
patch seals the dural puncture and relieves symptoms by stopping the leak.
, Why other options are incorrect:
• Analgesics alone: May not resolve underlying cause.
• Bed rest only: Already attempted without success.
• Antibiotics: Not indicated unless infection present.
DIF: Analysis
REF: Lumbar Puncture
OBJ: Manage complications of lumbar puncture
TOP: Complications
A hospitalized client becomes acutely confused with fluctuating levels of consciousness,
inattention, and disorganized thinking. What condition is being assessed using these findings?
Correct Answer:
Delirium (Confusion Assessment Method)
Expert Rationale:
The Confusion Assessment Method (CAM) identifies delirium based on acute onset, fluctuating
course, inattention, disorganized thinking, and altered level of consciousness. Delirium is often
reversible if the underlying cause is treated.
Why other options are incorrect:
• Dementia: Gradual onset, not acute.
• Depression: Does not cause fluctuating consciousness.
• Psychosis: Involves hallucinations/delusions primarily.
DIF: Analysis
REF: Cognitive Disorders
OBJ: Identify delirium using CAM
TOP: Assessment
A client is experiencing a tonic-clonic seizure. What is the nurse’s priority action?
Correct Answer:
Turn the client onto their side
Expert Rationale:
Turning the client onto their side helps maintain airway patency and reduces the risk of
aspiration during a seizure. Airway protection is the highest priority.
Why other options are incorrect:
• Insert object in mouth: Can cause injury.
• Restrain client: Increases risk of harm.
• Leave client unattended: Unsafe.
ACTUAL EXAM TEST BANK 200
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED
A+||NEWEST VERSION 2026/2027
A client is scheduled for a diagnostic procedure to evaluate cerebral blood flow and identify a
possible aneurysm. A catheter is inserted into the femoral artery, contrast dye is injected, and X-
ray images are obtained. What procedure is being performed?
Correct Answer:
Cerebral angiography
Expert Rationale:
Cerebral angiography is an invasive imaging procedure used to assess blood flow within the
brain, identify aneurysms, and evaluate tumor vascularity. A catheter is inserted into an artery
(commonly the femoral or carotid), contrast dye is injected, and X-rays are taken. After the
procedure, pressure or a closure device is applied to prevent bleeding. Clients often report a
warm sensation and metallic taste during dye injection.
Why other options are incorrect:
• CT scan: Noninvasive imaging, does not involve arterial catheterization.
• MRI: Uses magnetic fields, not contrast injection via catheter.
• EEG: Measures electrical activity, not blood flow.
DIF: Analysis
REF: Neurological Diagnostics
OBJ: Identify cerebral angiography procedure and purpose
TOP: Diagnostic Procedures
A client undergoing a cerebral angiography reports a sudden warm sensation in the face and a
metallic taste during the procedure. What is the nurse’s best interpretation?
,Correct Answer:
Normal reaction to contrast dye injection
Expert Rationale:
During cerebral angiography, injection of contrast dye commonly causes a transient warm
sensation and metallic taste. These are expected findings and do not indicate complications. The
nurse should reassure the client while continuing to monitor vital signs.
Why other options are incorrect:
• Allergic reaction: Would include rash, dyspnea, or hypotension.
• Stroke: Would present with neurological deficits.
• Hemorrhage: Would cause pain or swelling at insertion site.
DIF: Application
REF: Neurological Diagnostics
OBJ: Recognize normal findings during angiography
TOP: Nursing Care
A client with a Glasgow Coma Scale (GCS) score of 7 is admitted after a head injury. Which
intervention is most appropriate?
Correct Answer:
Initiate intracranial pressure (ICP) monitoring
Expert Rationale:
Clients with a GCS score of 8 or lower are candidates for ICP monitoring. Elevated ICP can
reduce cerebral perfusion and lead to brain death if untreated. Monitoring allows early
detection and management of increased pressure.
Why other options are incorrect:
• Routine observation only: Insufficient for severe impairment.
• Immediate discharge: Unsafe due to critical condition.
• EEG monitoring: Does not measure pressure changes.
DIF: Analysis
REF: Neurological Diagnostics
OBJ: Identify indications for ICP monitoring
TOP: Critical Care
A client presents with severe headache, dilated pupils, irregular respirations, and abnormal
posturing. What condition should the nurse suspect?
Correct Answer:
Increased intracranial pressure
,Expert Rationale:
Signs of increased ICP include severe headache, pupillary changes, altered breathing patterns,
and motor deterioration such as abnormal posturing. Elevated ICP compromises cerebral
circulation and requires urgent intervention.
Why other options are incorrect:
• Hypoglycemia: Causes confusion but not posturing.
• Seizure disorder: Symptoms are episodic, not persistent.
• Meningitis: Includes fever and neck stiffness primarily.
DIF: Analysis
REF: Neurological Diagnostics
OBJ: Recognize signs of increased ICP
TOP: Pathophysiology
A client undergoes a lumbar puncture. Which post-procedure intervention is most important?
Correct Answer:
Keep the client lying flat for several hours
Expert Rationale:
After a lumbar puncture, the client should remain flat to reduce the risk of cerebrospinal fluid
(CSF) leakage, which can cause severe headaches. Monitoring the puncture site is also essential
to ensure proper clotting.
Why other options are incorrect:
• Immediate ambulation: Increases risk of CSF leak.
• Elevating the head: Can worsen headache.
• Restricting fluids: Hydration actually helps recovery.
DIF: Application
REF: Lumbar Puncture
OBJ: Identify post-procedure care
TOP: Nursing Interventions
A client develops a severe headache after a lumbar puncture that does not resolve with rest.
What is the most appropriate intervention?
Correct Answer:
Prepare for an epidural blood patch
Expert Rationale:
Persistent headache after lumbar puncture is usually due to CSF leakage. An epidural blood
patch seals the dural puncture and relieves symptoms by stopping the leak.
, Why other options are incorrect:
• Analgesics alone: May not resolve underlying cause.
• Bed rest only: Already attempted without success.
• Antibiotics: Not indicated unless infection present.
DIF: Analysis
REF: Lumbar Puncture
OBJ: Manage complications of lumbar puncture
TOP: Complications
A hospitalized client becomes acutely confused with fluctuating levels of consciousness,
inattention, and disorganized thinking. What condition is being assessed using these findings?
Correct Answer:
Delirium (Confusion Assessment Method)
Expert Rationale:
The Confusion Assessment Method (CAM) identifies delirium based on acute onset, fluctuating
course, inattention, disorganized thinking, and altered level of consciousness. Delirium is often
reversible if the underlying cause is treated.
Why other options are incorrect:
• Dementia: Gradual onset, not acute.
• Depression: Does not cause fluctuating consciousness.
• Psychosis: Involves hallucinations/delusions primarily.
DIF: Analysis
REF: Cognitive Disorders
OBJ: Identify delirium using CAM
TOP: Assessment
A client is experiencing a tonic-clonic seizure. What is the nurse’s priority action?
Correct Answer:
Turn the client onto their side
Expert Rationale:
Turning the client onto their side helps maintain airway patency and reduces the risk of
aspiration during a seizure. Airway protection is the highest priority.
Why other options are incorrect:
• Insert object in mouth: Can cause injury.
• Restrain client: Increases risk of harm.
• Leave client unattended: Unsafe.
