NUR 220 | NUR 220 Medical Surgical Nursing Exam
4 Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. Which of the following components are evaluated when using the Glasgow Coma
Scale (GCS)?
A. Pupillary response, blood pressure, and motor strength.
B. Reflexes, respiratory rate, and level of consciousness.
C. Orientation, memory, and cognitive processing.
D. Eye opening, verbal response, and motor response.
Correct Answer: D
Expert Explanation: The Glasgow Coma Scale is a standardized clinical tool used to
objectively measure a patient’s level of consciousness. It specifically assesses three
categories: eye opening, verbal response, and motor response. Each category is
assigned a numerical value, and the scores are summed to determine the overall
status. A total score ranges from 3 to 15, providing a clear indicator of neurological
impairment severity. Nurses rely on this scale to monitor for changes and facilitate
rapid communication among the healthcare team.
,2. A patient is suspected of having an acute ischemic stroke. Which diagnostic test is
the priority to perform first?
A. Magnetic Resonance Imaging (MRI)
B. Electroencephalogram (EEG)
C. Carotid Ultrasound
D. Non-contrast Computed Tomography (CT) scan
Correct Answer: D
Expert Explanation: A non-contrast CT scan is the initial gold standard for
evaluating a suspected stroke patient. Its primary purpose is to differentiate
between an ischemic stroke and a hemorrhagic stroke. This distinction is critical
because thrombolytic therapy can be fatal if administered to a patient with a brain
bleed. The scan is typically performed rapidly within the ‘golden hour’ of arrival to
the emergency department. Once a hemorrhage is ruled out, appropriate
interventions for ischemic stroke can safely proceed.
3. What is the primary goal of nursing care during the ictal phase of a generalized
tonic-clonic seizure?
A. To insert an oral airway to prevent tongue biting.
B. To maintain patient safety and protect the head from injury.
C. To restrain the patient’s limbs to prevent fractures.
,D. To administer oral anti-epileptic medications immediately.
Correct Answer: B
Expert Explanation: Patient safety is the absolute priority when a nurse witnesses
an active seizure. The nurse should move nearby furniture and place a soft item
under the patient’s head to prevent trauma. Restraining the patient is strictly
contraindicated as it can lead to muscle tears or bone fractures. Nothing should ever
be forced into the patient’s mouth due to the risk of airway obstruction or dental
damage. After the seizure ends, the nurse should turn the patient to the side to
maintain a patent airway.
4. A patient with a traumatic brain injury (TBI) exhibits Cushing’s Triad. Which signs
should the nurse document?
A. Tachycardia, hypotension, and tachypnea.
B. Bradycardia, hypertension with widening pulse pressure, and irregular
respirations.
C. Bradycardia, hypotension, and Cheyne-Stokes respirations.
D. Tachycardia, hypertension, and kussmaul respirations.
Correct Answer: B
Expert Explanation: Cushing’s Triad is a late and ominous sign of significantly
increased intracranial pressure (ICP). It consists of three specific physiological
, changes: bradycardia, hypertension with a widening pulse pressure, and irregular
respiratory patterns. This triad indicates that the brain is no longer able to
compensate for the pressure, leading to brainstem compression. Nurses must
recognize these signs immediately as they often precede brain herniation.
Emergency intervention is required to reduce ICP and prevent permanent
neurological damage or death.
5. Which clinical manifestation is most characteristic of a patient with a right-sided
stroke?
A. Aphasia and slow, cautious behavior.
B. Right-sided hemiplegia and anxiety.
C. Impulsiveness and impaired judgment.
D. Difficulty with math and language comprehension.
Correct Answer: C
Expert Explanation: Patients who suffer a stroke in the right hemisphere of the
brain often exhibit specific behavioral changes. These include impulsivity, a
tendency to minimize their deficits, and significantly impaired judgment. Because
they may not realize their limitations, these patients are at a very high risk for falls
and injuries. In contrast, left-sided stroke patients are typically more cautious,
anxious, and struggle with language-related tasks. Nursing care for right-brain
4 Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. Which of the following components are evaluated when using the Glasgow Coma
Scale (GCS)?
A. Pupillary response, blood pressure, and motor strength.
B. Reflexes, respiratory rate, and level of consciousness.
C. Orientation, memory, and cognitive processing.
D. Eye opening, verbal response, and motor response.
Correct Answer: D
Expert Explanation: The Glasgow Coma Scale is a standardized clinical tool used to
objectively measure a patient’s level of consciousness. It specifically assesses three
categories: eye opening, verbal response, and motor response. Each category is
assigned a numerical value, and the scores are summed to determine the overall
status. A total score ranges from 3 to 15, providing a clear indicator of neurological
impairment severity. Nurses rely on this scale to monitor for changes and facilitate
rapid communication among the healthcare team.
,2. A patient is suspected of having an acute ischemic stroke. Which diagnostic test is
the priority to perform first?
A. Magnetic Resonance Imaging (MRI)
B. Electroencephalogram (EEG)
C. Carotid Ultrasound
D. Non-contrast Computed Tomography (CT) scan
Correct Answer: D
Expert Explanation: A non-contrast CT scan is the initial gold standard for
evaluating a suspected stroke patient. Its primary purpose is to differentiate
between an ischemic stroke and a hemorrhagic stroke. This distinction is critical
because thrombolytic therapy can be fatal if administered to a patient with a brain
bleed. The scan is typically performed rapidly within the ‘golden hour’ of arrival to
the emergency department. Once a hemorrhage is ruled out, appropriate
interventions for ischemic stroke can safely proceed.
3. What is the primary goal of nursing care during the ictal phase of a generalized
tonic-clonic seizure?
A. To insert an oral airway to prevent tongue biting.
B. To maintain patient safety and protect the head from injury.
C. To restrain the patient’s limbs to prevent fractures.
,D. To administer oral anti-epileptic medications immediately.
Correct Answer: B
Expert Explanation: Patient safety is the absolute priority when a nurse witnesses
an active seizure. The nurse should move nearby furniture and place a soft item
under the patient’s head to prevent trauma. Restraining the patient is strictly
contraindicated as it can lead to muscle tears or bone fractures. Nothing should ever
be forced into the patient’s mouth due to the risk of airway obstruction or dental
damage. After the seizure ends, the nurse should turn the patient to the side to
maintain a patent airway.
4. A patient with a traumatic brain injury (TBI) exhibits Cushing’s Triad. Which signs
should the nurse document?
A. Tachycardia, hypotension, and tachypnea.
B. Bradycardia, hypertension with widening pulse pressure, and irregular
respirations.
C. Bradycardia, hypotension, and Cheyne-Stokes respirations.
D. Tachycardia, hypertension, and kussmaul respirations.
Correct Answer: B
Expert Explanation: Cushing’s Triad is a late and ominous sign of significantly
increased intracranial pressure (ICP). It consists of three specific physiological
, changes: bradycardia, hypertension with a widening pulse pressure, and irregular
respiratory patterns. This triad indicates that the brain is no longer able to
compensate for the pressure, leading to brainstem compression. Nurses must
recognize these signs immediately as they often precede brain herniation.
Emergency intervention is required to reduce ICP and prevent permanent
neurological damage or death.
5. Which clinical manifestation is most characteristic of a patient with a right-sided
stroke?
A. Aphasia and slow, cautious behavior.
B. Right-sided hemiplegia and anxiety.
C. Impulsiveness and impaired judgment.
D. Difficulty with math and language comprehension.
Correct Answer: C
Expert Explanation: Patients who suffer a stroke in the right hemisphere of the
brain often exhibit specific behavioral changes. These include impulsivity, a
tendency to minimize their deficits, and significantly impaired judgment. Because
they may not realize their limitations, these patients are at a very high risk for falls
and injuries. In contrast, left-sided stroke patients are typically more cautious,
anxious, and struggle with language-related tasks. Nursing care for right-brain
