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MEDSURG 2 EXAM 2 NEWEST 2025 ACTUAL
EXAM COMPLETE 100 QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
Which statement would the nurse include when teaching the assistive personnel (AP) about how to care for a client with cranial nerve II impairment?
- "Tell the client where food items are on the breakfast tray."
- "Place the client in a high-Fowler position for all meals."
- "Make sure the client's food is visually appetizing."
- "Assist the client by placing the fork in the left hand." -
ANSWER-ANS: A
Rationale; Cranial nerve II, the optic nerve, provides central and peripheral vision. A patient who has cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client where different food items are on the meal tray. The other options are not appropriate for client with cranial nerve II impairment.
A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which complication of this procedure would 1 / 4
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alert the nurse to urgently contact the primary health care provider?
- Weak pedal pulses
- Nausea and vomiting
- Increased thirst
d. Hives on the chest - ANSWER-ANS: B
Rationale; The nurse would immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.
A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How would the nurse document this client's assessment using the Glasgow Coma Scale?
- 8
- 10
- 12
d. 14 - ANSWER-ANS: C
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A nurse assesses a client with an injury to the medulla. Which clinical manifestations would the nurse expect to find? (Select all that apply.)
- Decreased respiratory rate
- Impaired swallowing
- Visual changes
- Inability to shrug shoulders
e. Loss of gag reflex - ANSWER-ANS: A, B, D, E
Rationale; Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic).Damage to these nerves causes decreased respirations, impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.
An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline. Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.)
- Chronic hearing loss
- Infection 3 / 4
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- Drug toxicity
- Dementia
- Hypoxia
f. Aging - ANSWER-ANS: B, C, E
Rationale; Acute client conditions that occur in older adults often cause acute confusion and associated emotional behaviors.Infection, drug toxicity, and hypoxia are all acute health problems that can contribute to the client's cognitive decline.Aging does not cause changes in cognition. If the client had dementia, he or she would not be alert and oriented. Having a chronic hearing loss is not a change in the client's condition.
A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.)
- Glasgow Coma Scale score of 8
- Decerebrate posturing
- Reactive pupils
- Uninhibited speech
e. Decreasing level of consciousness - ANSWER-ANS: A, B, E
Rationale; The nurse would urgently communicate changes in a patient's neurologic status, including a decrease in the Glasgow
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