NUR185/NUR 185 Exam 4 V1 | Concepts of
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client who is experiencing a suspected stroke. Which of the
following diagnostic tests should the nurse expect the provider to order first to rule out a
brain hemorrhage?
A. Magnetic Resonance Imaging (MRI)
B. Lumbar Puncture
C. Electroencephalogram (EEG)
D. Non-contrast Computed Tomography (CT) scan
Correct Answer: D
Rationale: A non-contrast CT scan is the gold standard for initially evaluating a client with
stroke symptoms. It is performed quickly to differentiate between an ischemic stroke and a
hemorrhagic stroke. This distinction is critical because the treatments for these two types
of strokes are vastly different and potentially harmful if misapplied.
2. A practical nurse is observing a client who had a left-hemisphere stroke. Which of the
following findings should the nurse expect to observe?
A. Impulsivity and poor judgment
,B. Left-sided hemiplegia
C. Aphasia and cautious behavior
D. Spatial-perceptual deficits
Correct Answer: C
Rationale: The left hemisphere of the brain is typically responsible for language and logical
reasoning. A client who has had a left-sided stroke will often exhibit aphasia, which is a
deficit in language expression or comprehension. These clients are also generally more
cautious and slow in their movements compared to those with right-sided damage.
3. The nurse is reinforcing teaching with a client who has been diagnosed with a Transient
Ischemic Attack (TIA). Which information is most important to include?
A. A TIA is a warning sign of an impending major stroke.
B. TIAs cause permanent brain damage within minutes.
C. Symptoms usually persist for several days after the event.
D. There is no need for follow-up if symptoms resolve quickly.
Correct Answer: A
Rationale: A TIA is defined as a temporary focal neurological deficit that usually resolves
within 24 hours. It serves as a significant warning sign that the client is at high risk for a
major ischemic stroke in the near future. Nurses must emphasize that the client needs
immediate medical evaluation and lifestyle modifications to prevent a full stroke.
, 4. A nurse is performing a Glasgow Coma Scale (GCS) assessment on a client. The client opens
their eyes to sound, uses inappropriate words, and withdraws from pain. What is the
calculated GCS score?
A. 12
B. 15
C. 8
D. 10
Correct Answer: D
Rationale: The GCS measures eye-opening, verbal response, and motor response. In this
scenario, opening eyes to sound scores a 3, inappropriate words score a 3, and
withdrawing from pain scores a 4, totaling 10. A score of 15 is the highest possible, while a
score of 8 or less typically indicates a severe brain injury.
5. Which of the following clinical manifestations is considered an early sign of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Fixed and dilated pupils
C. Decreased level of consciousness
D. Bradycardia
Correct Answer: C
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client who is experiencing a suspected stroke. Which of the
following diagnostic tests should the nurse expect the provider to order first to rule out a
brain hemorrhage?
A. Magnetic Resonance Imaging (MRI)
B. Lumbar Puncture
C. Electroencephalogram (EEG)
D. Non-contrast Computed Tomography (CT) scan
Correct Answer: D
Rationale: A non-contrast CT scan is the gold standard for initially evaluating a client with
stroke symptoms. It is performed quickly to differentiate between an ischemic stroke and a
hemorrhagic stroke. This distinction is critical because the treatments for these two types
of strokes are vastly different and potentially harmful if misapplied.
2. A practical nurse is observing a client who had a left-hemisphere stroke. Which of the
following findings should the nurse expect to observe?
A. Impulsivity and poor judgment
,B. Left-sided hemiplegia
C. Aphasia and cautious behavior
D. Spatial-perceptual deficits
Correct Answer: C
Rationale: The left hemisphere of the brain is typically responsible for language and logical
reasoning. A client who has had a left-sided stroke will often exhibit aphasia, which is a
deficit in language expression or comprehension. These clients are also generally more
cautious and slow in their movements compared to those with right-sided damage.
3. The nurse is reinforcing teaching with a client who has been diagnosed with a Transient
Ischemic Attack (TIA). Which information is most important to include?
A. A TIA is a warning sign of an impending major stroke.
B. TIAs cause permanent brain damage within minutes.
C. Symptoms usually persist for several days after the event.
D. There is no need for follow-up if symptoms resolve quickly.
Correct Answer: A
Rationale: A TIA is defined as a temporary focal neurological deficit that usually resolves
within 24 hours. It serves as a significant warning sign that the client is at high risk for a
major ischemic stroke in the near future. Nurses must emphasize that the client needs
immediate medical evaluation and lifestyle modifications to prevent a full stroke.
, 4. A nurse is performing a Glasgow Coma Scale (GCS) assessment on a client. The client opens
their eyes to sound, uses inappropriate words, and withdraws from pain. What is the
calculated GCS score?
A. 12
B. 15
C. 8
D. 10
Correct Answer: D
Rationale: The GCS measures eye-opening, verbal response, and motor response. In this
scenario, opening eyes to sound scores a 3, inappropriate words score a 3, and
withdrawing from pain scores a 4, totaling 10. A score of 15 is the highest possible, while a
score of 8 or less typically indicates a severe brain injury.
5. Which of the following clinical manifestations is considered an early sign of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Fixed and dilated pupils
C. Decreased level of consciousness
D. Bradycardia
Correct Answer: C
