NUR 205 | NUR 205 Med Surg Exam 4 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is assessing a client who just arrived in the emergency department with a
suspected stroke. Which of the following is the priority assessment to perform first?
A. Check the client’s blood glucose level.
B. Assess the client’s visual acuity.
C. Obtain a full medical history from the family.
D. Determine the time of onset of symptoms.
Correct Answer: D
Expert Explanation: Determining the time of onset is critical because it dictates the
eligibility for fibrinolytic therapy like alteplase. Alteplase must typically be
administered within a three to four-and-a-half-hour window of symptom start.
While blood glucose is important to rule out hypoglycemia, the ‘last known well’
time is the primary factor for emergency stroke protocols. Rapid identification of
the stroke type via CT scan follows this initial assessment. The nurse must prioritize
time-sensitive interventions to improve patient outcomes in neurological
emergencies.
,2. Which of the following clinical manifestations is considered the earliest sign of
increased intracranial pressure (ICP)?
A. Cushing’s Triad
B. Change in level of consciousness (LOC)
C. Ipsilateral pupil dilation
D. Decerebrate posturing
Correct Answer: B
Expert Explanation: A change in the level of consciousness is the most sensitive
and earliest indicator of neurological deterioration. This occurs as brain tissue
becomes sensitive to even slight decreases in oxygenation and blood flow. Later
signs include pupillary changes and motor dysfunction such as posturing. Cushing’s
Triad, which involves bradycardia and widening pulse pressure, is a very late sign
suggesting imminent herniation. Nurses must perform frequent Glasgow Coma Scale
assessments to detect these subtle changes early.
3. A patient is experiencing a tonic-clonic seizure. What is the nurse’s priority action
during the active seizure phase?
A. Turn the client to the side.
B. Restrain the client’s limbs to prevent injury.
C. Insert a padded tongue blade into the mouth.
,D. Administer oral anticonvulsants immediately.
Correct Answer: A
Expert Explanation: Turning the client to the side is vital to maintain airway
patency and prevent aspiration of secretions. Restraining the patient or inserting
objects into the mouth can cause serious physical injury or airway obstruction. The
nurse should clear the area of hazards and protect the patient’s head from hitting
hard surfaces. Documentation of the seizure’s duration and characteristics should
occur after the patient is safe. Monitoring the respiratory status remains the
primary focus throughout the ictal and postictal phases.
4. A nurse is caring for a client with a Glasgow Coma Scale (GCS) score of 7. How
should the nurse interpret this finding?
A. The client is alert and oriented.
B. The client is in a comatose state.
C. The client has a mild brain injury.
D. The client has normal neurological function.
Correct Answer: B
Expert Explanation: A Glasgow Coma Scale score of 8 or less is generally defined as
a comatose state indicating severe brain injury. The GCS measures eye-opening,
verbal response, and motor response to determine neurological depth. A score of 7
, suggests the client requires significant airway management and monitoring. The
highest possible score is 15, which indicates a fully awake and oriented individual.
Prompt medical intervention is necessary for any patient scoring below 8 to prevent
further brain damage.
5. The nurse identifies Cushing’s Triad in a patient with a head injury. Which set of
vital signs reflects this condition?
A. BP 160/60, HR 50, irregular respirations
B. BP 90/50, HR 120, rapid respirations
C. BP 120/80, HR 80, normal respirations
D. BP 110/70, HR 110, shallow respirations
Correct Answer: A
Expert Explanation: Cushing’s Triad consists of hypertension with a widening
pulse pressure, bradycardia, and irregular respiratory patterns. This triad is a
compensatory response to significantly increased intracranial pressure and
impending brain herniation. It indicates that the brain can no longer compensate for
the pressure within the skull. The other options describe hypovolemic shock or
normal vital signs which are unrelated to this neurological phenomenon. Immediate
notification of the surgical or neurological team is mandatory when this triad is
observed.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is assessing a client who just arrived in the emergency department with a
suspected stroke. Which of the following is the priority assessment to perform first?
A. Check the client’s blood glucose level.
B. Assess the client’s visual acuity.
C. Obtain a full medical history from the family.
D. Determine the time of onset of symptoms.
Correct Answer: D
Expert Explanation: Determining the time of onset is critical because it dictates the
eligibility for fibrinolytic therapy like alteplase. Alteplase must typically be
administered within a three to four-and-a-half-hour window of symptom start.
While blood glucose is important to rule out hypoglycemia, the ‘last known well’
time is the primary factor for emergency stroke protocols. Rapid identification of
the stroke type via CT scan follows this initial assessment. The nurse must prioritize
time-sensitive interventions to improve patient outcomes in neurological
emergencies.
,2. Which of the following clinical manifestations is considered the earliest sign of
increased intracranial pressure (ICP)?
A. Cushing’s Triad
B. Change in level of consciousness (LOC)
C. Ipsilateral pupil dilation
D. Decerebrate posturing
Correct Answer: B
Expert Explanation: A change in the level of consciousness is the most sensitive
and earliest indicator of neurological deterioration. This occurs as brain tissue
becomes sensitive to even slight decreases in oxygenation and blood flow. Later
signs include pupillary changes and motor dysfunction such as posturing. Cushing’s
Triad, which involves bradycardia and widening pulse pressure, is a very late sign
suggesting imminent herniation. Nurses must perform frequent Glasgow Coma Scale
assessments to detect these subtle changes early.
3. A patient is experiencing a tonic-clonic seizure. What is the nurse’s priority action
during the active seizure phase?
A. Turn the client to the side.
B. Restrain the client’s limbs to prevent injury.
C. Insert a padded tongue blade into the mouth.
,D. Administer oral anticonvulsants immediately.
Correct Answer: A
Expert Explanation: Turning the client to the side is vital to maintain airway
patency and prevent aspiration of secretions. Restraining the patient or inserting
objects into the mouth can cause serious physical injury or airway obstruction. The
nurse should clear the area of hazards and protect the patient’s head from hitting
hard surfaces. Documentation of the seizure’s duration and characteristics should
occur after the patient is safe. Monitoring the respiratory status remains the
primary focus throughout the ictal and postictal phases.
4. A nurse is caring for a client with a Glasgow Coma Scale (GCS) score of 7. How
should the nurse interpret this finding?
A. The client is alert and oriented.
B. The client is in a comatose state.
C. The client has a mild brain injury.
D. The client has normal neurological function.
Correct Answer: B
Expert Explanation: A Glasgow Coma Scale score of 8 or less is generally defined as
a comatose state indicating severe brain injury. The GCS measures eye-opening,
verbal response, and motor response to determine neurological depth. A score of 7
, suggests the client requires significant airway management and monitoring. The
highest possible score is 15, which indicates a fully awake and oriented individual.
Prompt medical intervention is necessary for any patient scoring below 8 to prevent
further brain damage.
5. The nurse identifies Cushing’s Triad in a patient with a head injury. Which set of
vital signs reflects this condition?
A. BP 160/60, HR 50, irregular respirations
B. BP 90/50, HR 120, rapid respirations
C. BP 120/80, HR 80, normal respirations
D. BP 110/70, HR 110, shallow respirations
Correct Answer: A
Expert Explanation: Cushing’s Triad consists of hypertension with a widening
pulse pressure, bradycardia, and irregular respiratory patterns. This triad is a
compensatory response to significantly increased intracranial pressure and
impending brain herniation. It indicates that the brain can no longer compensate for
the pressure within the skull. The other options describe hypovolemic shock or
normal vital signs which are unrelated to this neurological phenomenon. Immediate
notification of the surgical or neurological team is mandatory when this triad is
observed.
