NUR201 Medical Surgical Exam 4 Version 1
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient arrives in the emergency department with sudden onset of right-sided
weakness and aphasia. Which diagnostic test should the nurse prioritize first?
A. Non-contrast Computed Tomography (CT) scan
B. Magnetic Resonance Imaging (MRI)
C. Lumbar puncture
D. Carotid ultrasound
Correct Answer: A
Expert Explanation: A non-contrast CT scan is the gold standard for initially
assessing a patient with suspected stroke. It allows the medical team to quickly
differentiate between ischemic and hemorrhagic strokes. This differentiation is vital
because fibrinolytic therapy is strictly contraindicated in cases of intracranial
hemorrhage. The goal is to perform and interpret the CT within 45 minutes of the
patient’s arrival. Timely diagnosis ensures that eligible patients receive reperfusion
therapy within the appropriate window.
2. Which assessment finding should the nurse identify as a component of Cushing’s
Triad in a patient with increased intracranial pressure (ICP)?
A. Irregular respirations
,B. Hypotension
C. Tachycardia
D. Narrowing pulse pressure
Correct Answer: A
Expert Explanation: Cushing’s Triad is a late sign of significantly increased
intracranial pressure and impending brain herniation. It consists of bradycardia,
widening pulse pressure, and irregular respiratory patterns. These symptoms occur
as the brainstem becomes compressed due to the rising pressure within the skull.
Recognizing these signs early is crucial for emergency intervention to prevent
permanent neurological damage. The nurse must notify the provider immediately if
these physiological changes are observed.
3. The nurse is using the Glasgow Coma Scale (GCS) to assess a patient. The patient
opens eyes to sound, uses inappropriate words, and withdraws from painful stimuli.
What is the total score?
A. 9
B. 11
C. 10
D. 12
,Correct Answer: C
Expert Explanation: The Glasgow Coma Scale assesses three main categories: eye
opening, verbal response, and motor response. Opening eyes to sound earns 3
points, while inappropriate speech earns 3 points. Withdrawing from painful stimuli
is assigned a motor score of 4 points. Adding these values together results in a total
GCS score of 10. A score between 9 and 12 generally indicates a moderate brain
injury requiring close monitoring.
4. During a tonic-clonic seizure, which nursing action is the highest priority?
A. Inserting a padded tongue blade
B. Restraining the patient’s limbs
C. Turning the patient to a side-lying position
D. Administering oral phenytoin immediately
Correct Answer: C
Expert Explanation: Maintaining a patent airway is the primary goal during an
active seizure event. Turning the patient to their side helps prevent aspiration by
allowing secretions to drain from the mouth. Nothing should ever be placed in the
patient’s mouth during a seizure to avoid injury or airway obstruction. Restraints
should be avoided because they can lead to musculoskeletal injuries during the
, tonic-clonic phase. Safety precautions include protecting the head and removing
nearby hazardous objects.
5. A patient with a traumatic brain injury is prescribed Mannitol 25%. Which nursing
intervention is specific to the administration of this medication?
A. Monitoring for hyperkalemia
B. Limiting fluid intake to 500 mL per day
C. Administering only through a central line
D. Using a filtered needle and in-line filter
Correct Answer: D
Expert Explanation: Mannitol is an osmotic diuretic used to reduce cerebral edema
and intracranial pressure. This medication can crystallize at room temperature,
making inspection of the vial essential. A filtered needle must be used to draw up
the medication, and an in-line filter is required for administration. The nurse must
also monitor strict intake and output to assess the drug’s effectiveness. Electrolyte
levels should be checked frequently because Mannitol can cause significant
dehydration and imbalances.
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient arrives in the emergency department with sudden onset of right-sided
weakness and aphasia. Which diagnostic test should the nurse prioritize first?
A. Non-contrast Computed Tomography (CT) scan
B. Magnetic Resonance Imaging (MRI)
C. Lumbar puncture
D. Carotid ultrasound
Correct Answer: A
Expert Explanation: A non-contrast CT scan is the gold standard for initially
assessing a patient with suspected stroke. It allows the medical team to quickly
differentiate between ischemic and hemorrhagic strokes. This differentiation is vital
because fibrinolytic therapy is strictly contraindicated in cases of intracranial
hemorrhage. The goal is to perform and interpret the CT within 45 minutes of the
patient’s arrival. Timely diagnosis ensures that eligible patients receive reperfusion
therapy within the appropriate window.
2. Which assessment finding should the nurse identify as a component of Cushing’s
Triad in a patient with increased intracranial pressure (ICP)?
A. Irregular respirations
,B. Hypotension
C. Tachycardia
D. Narrowing pulse pressure
Correct Answer: A
Expert Explanation: Cushing’s Triad is a late sign of significantly increased
intracranial pressure and impending brain herniation. It consists of bradycardia,
widening pulse pressure, and irregular respiratory patterns. These symptoms occur
as the brainstem becomes compressed due to the rising pressure within the skull.
Recognizing these signs early is crucial for emergency intervention to prevent
permanent neurological damage. The nurse must notify the provider immediately if
these physiological changes are observed.
3. The nurse is using the Glasgow Coma Scale (GCS) to assess a patient. The patient
opens eyes to sound, uses inappropriate words, and withdraws from painful stimuli.
What is the total score?
A. 9
B. 11
C. 10
D. 12
,Correct Answer: C
Expert Explanation: The Glasgow Coma Scale assesses three main categories: eye
opening, verbal response, and motor response. Opening eyes to sound earns 3
points, while inappropriate speech earns 3 points. Withdrawing from painful stimuli
is assigned a motor score of 4 points. Adding these values together results in a total
GCS score of 10. A score between 9 and 12 generally indicates a moderate brain
injury requiring close monitoring.
4. During a tonic-clonic seizure, which nursing action is the highest priority?
A. Inserting a padded tongue blade
B. Restraining the patient’s limbs
C. Turning the patient to a side-lying position
D. Administering oral phenytoin immediately
Correct Answer: C
Expert Explanation: Maintaining a patent airway is the primary goal during an
active seizure event. Turning the patient to their side helps prevent aspiration by
allowing secretions to drain from the mouth. Nothing should ever be placed in the
patient’s mouth during a seizure to avoid injury or airway obstruction. Restraints
should be avoided because they can lead to musculoskeletal injuries during the
, tonic-clonic phase. Safety precautions include protecting the head and removing
nearby hazardous objects.
5. A patient with a traumatic brain injury is prescribed Mannitol 25%. Which nursing
intervention is specific to the administration of this medication?
A. Monitoring for hyperkalemia
B. Limiting fluid intake to 500 mL per day
C. Administering only through a central line
D. Using a filtered needle and in-line filter
Correct Answer: D
Expert Explanation: Mannitol is an osmotic diuretic used to reduce cerebral edema
and intracranial pressure. This medication can crystallize at room temperature,
making inspection of the vial essential. A filtered needle must be used to draw up
the medication, and an in-line filter is required for administration. The nurse must
also monitor strict intake and output to assess the drug’s effectiveness. Electrolyte
levels should be checked frequently because Mannitol can cause significant
dehydration and imbalances.
