NUR104 | NUR104 Medsurg 2 Exam 3 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a patient who just experienced a generalized tonic-clonic
seizure. Which nursing intervention is the priority during the post-ictal phase?
A. Assessing the patient’s airway and suctioning as needed
B. Administering oral anti-epileptic medication immediately
C. Restraining the patient to prevent further injury
D. Documenting the duration of the seizure activity
Correct Answer: A
Expert Explanation: The primary concern during the post-ictal phase is
maintaining a patent airway due to potential secretions or tongue obstruction.
Muscle relaxation following the seizure can lead to respiratory compromise if the
airway is not monitored. Suctioning may be required to clear the oropharynx of
excess saliva or vomit to prevent aspiration. Restraints are never used as they can
cause physical injury to the patient during or after a seizure. Ensuring adequate
oxygenation is the critical first step before focusing on documentation or long-term
medication management.
,2. A patient with a traumatic brain injury has a Glascow Coma Scale (GCS) score of 7.
How should the nurse interpret this finding?
A. The patient is alert and oriented to person and place
B. The patient is in a coma and requires airway protection
C. The patient has a mild concussion
D. The patient is exhibiting normal neurological function
Correct Answer: B
Expert Explanation: A Glascow Coma Scale score of 8 or less is the clinical
definition for a comatose state in a patient. This low score indicates a severe
impairment in neurological response, including eye opening, verbal, and motor
functions. Patients with a score of 7 typically lack the protective reflexes necessary
to maintain their own airway. Therefore, the medical team must prioritize
intubation and mechanical ventilation to ensure safety. Monitoring for further
decline is essential as any decrease in the GCS score signifies worsening brain injury.
3. Which of the following assessments is considered a late sign of increased
intracranial pressure (ICP)?
A. Restlessness and irritability
B. Constant, dull headache
C. Cushing’s triad
,D. Slightly blurred vision
Correct Answer: C
Expert Explanation: Cushing’s triad consists of bradycardia, hypertension with a
widening pulse pressure, and irregular respirations. This physiological phenomenon
is a late manifestation of significant brainstem compression and high ICP. Early
signs of increased pressure usually include subtle changes in mental status like
restlessness or confusion. While headaches and blurred vision are concerning, they
often precede the dangerous hemodynamic changes seen in the triad. The presence
of these symptoms indicates that the brain is near the point of herniation,
necessitating immediate emergency care.
4. The nurse is preparing to administer Mannitol to a patient with cerebral edema.
What is the primary mechanism of action for this medication?
A. Creating an osmotic gradient to pull fluid from brain tissue into the blood
B. Decreasing blood pressure to reduce cerebral blood flow
C. Blocking the production of cerebrospinal fluid
D. Providing sedation to lower the metabolic demands of the brain
Correct Answer: A
Expert Explanation: Mannitol is an osmotic diuretic that increases the osmolarity
of the blood relative to the brain tissue. This gradient causes water to move out of
, the swollen brain cells and into the vascular space for excretion by the kidneys. It is
the gold standard for rapidly reducing intracranial pressure in emergency
neurological situations. The nurse must monitor the patient’s urine output and
serum electrolytes closely during administration. Unlike standard diuretics,
Mannitol specifically targets the reduction of cerebral edema to prevent secondary
brain injury.
5. A patient who had an ischemic stroke 2 hours ago is being evaluated for tissue
plasminogen activator (tPA). Which finding would exclude the patient from receiving
this therapy?
A. History of a major surgical procedure 10 days ago
B. A blood glucose level of 110 mg/dL
C. Age older than 50 years
D. Onset of symptoms occurred 2 hours ago
Correct Answer: A
Expert Explanation: Recent major surgery within the last 14 days is a relative
contraindication for fibrinolytic therapy like tPA due to the high risk of internal
bleeding. The medication dissolves all existing clots, which could lead to fatal
hemorrhaging at a recent surgical site. Age and normal glucose levels are not
reasons to withhold this life-saving stroke intervention. Because the patient is
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a patient who just experienced a generalized tonic-clonic
seizure. Which nursing intervention is the priority during the post-ictal phase?
A. Assessing the patient’s airway and suctioning as needed
B. Administering oral anti-epileptic medication immediately
C. Restraining the patient to prevent further injury
D. Documenting the duration of the seizure activity
Correct Answer: A
Expert Explanation: The primary concern during the post-ictal phase is
maintaining a patent airway due to potential secretions or tongue obstruction.
Muscle relaxation following the seizure can lead to respiratory compromise if the
airway is not monitored. Suctioning may be required to clear the oropharynx of
excess saliva or vomit to prevent aspiration. Restraints are never used as they can
cause physical injury to the patient during or after a seizure. Ensuring adequate
oxygenation is the critical first step before focusing on documentation or long-term
medication management.
,2. A patient with a traumatic brain injury has a Glascow Coma Scale (GCS) score of 7.
How should the nurse interpret this finding?
A. The patient is alert and oriented to person and place
B. The patient is in a coma and requires airway protection
C. The patient has a mild concussion
D. The patient is exhibiting normal neurological function
Correct Answer: B
Expert Explanation: A Glascow Coma Scale score of 8 or less is the clinical
definition for a comatose state in a patient. This low score indicates a severe
impairment in neurological response, including eye opening, verbal, and motor
functions. Patients with a score of 7 typically lack the protective reflexes necessary
to maintain their own airway. Therefore, the medical team must prioritize
intubation and mechanical ventilation to ensure safety. Monitoring for further
decline is essential as any decrease in the GCS score signifies worsening brain injury.
3. Which of the following assessments is considered a late sign of increased
intracranial pressure (ICP)?
A. Restlessness and irritability
B. Constant, dull headache
C. Cushing’s triad
,D. Slightly blurred vision
Correct Answer: C
Expert Explanation: Cushing’s triad consists of bradycardia, hypertension with a
widening pulse pressure, and irregular respirations. This physiological phenomenon
is a late manifestation of significant brainstem compression and high ICP. Early
signs of increased pressure usually include subtle changes in mental status like
restlessness or confusion. While headaches and blurred vision are concerning, they
often precede the dangerous hemodynamic changes seen in the triad. The presence
of these symptoms indicates that the brain is near the point of herniation,
necessitating immediate emergency care.
4. The nurse is preparing to administer Mannitol to a patient with cerebral edema.
What is the primary mechanism of action for this medication?
A. Creating an osmotic gradient to pull fluid from brain tissue into the blood
B. Decreasing blood pressure to reduce cerebral blood flow
C. Blocking the production of cerebrospinal fluid
D. Providing sedation to lower the metabolic demands of the brain
Correct Answer: A
Expert Explanation: Mannitol is an osmotic diuretic that increases the osmolarity
of the blood relative to the brain tissue. This gradient causes water to move out of
, the swollen brain cells and into the vascular space for excretion by the kidneys. It is
the gold standard for rapidly reducing intracranial pressure in emergency
neurological situations. The nurse must monitor the patient’s urine output and
serum electrolytes closely during administration. Unlike standard diuretics,
Mannitol specifically targets the reduction of cerebral edema to prevent secondary
brain injury.
5. A patient who had an ischemic stroke 2 hours ago is being evaluated for tissue
plasminogen activator (tPA). Which finding would exclude the patient from receiving
this therapy?
A. History of a major surgical procedure 10 days ago
B. A blood glucose level of 110 mg/dL
C. Age older than 50 years
D. Onset of symptoms occurred 2 hours ago
Correct Answer: A
Expert Explanation: Recent major surgery within the last 14 days is a relative
contraindication for fibrinolytic therapy like tPA due to the high risk of internal
bleeding. The medication dissolves all existing clots, which could lead to fatal
hemorrhaging at a recent surgical site. Age and normal glucose levels are not
reasons to withhold this life-saving stroke intervention. Because the patient is
