NUR185/NUR 185 Exam 3 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 patient who just experienced a tonic-clonic seizure. Which action
should the nurse take first during the post-ictal phase?
A. Administer oral fluids immediately.
B. Restrain the patient’s limbs to prevent injury.
C. Place the patient in a side-lying position.
D. Perform a complete neurological assessment.
Correct Answer: C
Rationale: The post-ictal phase requires maintaining a patent airway and preventing
aspiration. Placing the patient in a side-lying position allows secretions to drain and keeps
the tongue from obstructing the airway. The nurse should monitor the patient until they
are fully awake and alert.
2. A patient with a spinal cord injury at the T4 level reports a sudden severe headache and
nasal congestion. The nurse notes the blood pressure is 180/100 mmHg. What is the priority
intervention?
A. Administer an ordered PRN analgesic for the headache.
,B. Check the patient’s bladder for distention.
C. Notify the healthcare provider immediately.
D. Lower the head of the bed to a flat position.
Correct Answer: B
Rationale: The symptoms of severe headache and hypertension in a patient with a high
spinal cord injury indicate autonomic dysreflexia. This condition is often triggered by a full
bladder or impacted bowel. Identifying and removing the stimulus, such as emptying the
bladder, is the priority to resolve the hypertensive crisis.
3. Which Glasgow Coma Scale (GCS) score would prompt the nurse to prepare for immediate
intubation and mechanical ventilation?
A. GCS of 15
B. GCS of 12
C. GCS of 8
D. GCS of 10
Correct Answer: C
Rationale: A Glasgow Coma Scale score of 8 or less typically indicates that the patient is in
a coma. At this level, the patient is unable to protect their own airway. Preparation for
intubation is a priority to ensure adequate oxygenation and ventilation.
, 4. The nurse is assessing a patient with suspected meningitis. Which clinical finding is most
indicative of meningeal irritation?
A. Nuchal rigidity
B. Negative Babinski reflex
C. Bradypnea
D. Hypotension
Correct Answer: A
Rationale: Nuchal rigidity, or neck stiffness, is a classic sign of meningeal irritation. It
occurs due to inflammation of the membranes surrounding the brain and spinal cord. Other
signs include Kernig’s and Brudzinski’s signs which are often tested during the physical
exam.
5. A patient presents with ‘the worst headache of my life.’ The nurse suspects a hemorrhagic
stroke. Which diagnostic test is the priority to confirm the diagnosis?
A. Magnetic Resonance Imaging (MRI)
B. Computed Tomography (CT) scan without contrast
C. Lumbar puncture
D. Electroencephalogram (EEG)
Correct Answer: B
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient who just experienced a tonic-clonic seizure. Which action
should the nurse take first during the post-ictal phase?
A. Administer oral fluids immediately.
B. Restrain the patient’s limbs to prevent injury.
C. Place the patient in a side-lying position.
D. Perform a complete neurological assessment.
Correct Answer: C
Rationale: The post-ictal phase requires maintaining a patent airway and preventing
aspiration. Placing the patient in a side-lying position allows secretions to drain and keeps
the tongue from obstructing the airway. The nurse should monitor the patient until they
are fully awake and alert.
2. A patient with a spinal cord injury at the T4 level reports a sudden severe headache and
nasal congestion. The nurse notes the blood pressure is 180/100 mmHg. What is the priority
intervention?
A. Administer an ordered PRN analgesic for the headache.
,B. Check the patient’s bladder for distention.
C. Notify the healthcare provider immediately.
D. Lower the head of the bed to a flat position.
Correct Answer: B
Rationale: The symptoms of severe headache and hypertension in a patient with a high
spinal cord injury indicate autonomic dysreflexia. This condition is often triggered by a full
bladder or impacted bowel. Identifying and removing the stimulus, such as emptying the
bladder, is the priority to resolve the hypertensive crisis.
3. Which Glasgow Coma Scale (GCS) score would prompt the nurse to prepare for immediate
intubation and mechanical ventilation?
A. GCS of 15
B. GCS of 12
C. GCS of 8
D. GCS of 10
Correct Answer: C
Rationale: A Glasgow Coma Scale score of 8 or less typically indicates that the patient is in
a coma. At this level, the patient is unable to protect their own airway. Preparation for
intubation is a priority to ensure adequate oxygenation and ventilation.
, 4. The nurse is assessing a patient with suspected meningitis. Which clinical finding is most
indicative of meningeal irritation?
A. Nuchal rigidity
B. Negative Babinski reflex
C. Bradypnea
D. Hypotension
Correct Answer: A
Rationale: Nuchal rigidity, or neck stiffness, is a classic sign of meningeal irritation. It
occurs due to inflammation of the membranes surrounding the brain and spinal cord. Other
signs include Kernig’s and Brudzinski’s signs which are often tested during the physical
exam.
5. A patient presents with ‘the worst headache of my life.’ The nurse suspects a hemorrhagic
stroke. Which diagnostic test is the priority to confirm the diagnosis?
A. Magnetic Resonance Imaging (MRI)
B. Computed Tomography (CT) scan without contrast
C. Lumbar puncture
D. Electroencephalogram (EEG)
Correct Answer: B
