NUR 265 MEDICAL-SURGICAL NURSING EXAM 4 2026 |
Galen College of Nursing | 100% Correct | Med Surg Test |
Pass Guaranteed - A+ Graded
Section 1: Neurologic Disorders - Stroke, Seizures, Head Injury,
Increased ICP (Q1-20)
Question 1
A 68-year-old male is admitted with sudden onset right-sided hemiparesis, aphasia,
and a National Institutes of Health Stroke Scale (NIHSS) score of 18. CT scan shows
no hemorrhage. The patient's last known well time was 2.5 hours ago. Vital signs are
stable. Which intervention is the nurse's HIGHEST priority?
A. Initiate aspirin 325 mg orally immediately.
B. Prepare the patient for possible administration of alteplase (tPA) after confirming
eligibility criteria.
C. Insert a nasogastric tube for enteral feeding due to aspiration risk.
D. Apply bilateral wrist restraints to prevent falls from hemiparesis.
Correct Answer: B
B is correct because the patient meets critical tPA criteria: ischemic stroke confirmed
by CT (no hemorrhage), NIHSS score indicating moderate-severe deficit (appropriate
for intervention), and within the 3-4.5 hour therapeutic window. Aspirin is
contraindicated within 24 hours of tPA. NG tube insertion is premature without
swallowing assessment. Restraints are inappropriate and violate patient rights.
Question 2
,A nurse is caring for a patient 24 hours post-tPA administration for ischemic stroke.
Which assessment finding requires IMMEDIATE notification of the healthcare
provider?
A. Blood pressure 148/92 mmHg.
B. Sudden severe headache with decreased level of consciousness.
C. Mild ecchymosis at the IV insertion site.
D. Temperature 99.1°F (37.3°C).
Correct Answer: B
B indicates potential hemorrhagic transformation post-tPA—the most feared
complication requiring immediate provider notification and likely emergent CT
imaging. A represents mild post-stroke hypertension manageable with ordered
antihypertensives. C is expected minor bleeding from thrombolytic therapy. D is low-
grade fever without clinical significance.
Question 3
A patient with a right-hemispheric stroke exhibits left-sided unilateral neglect. Which
nursing intervention is MOST appropriate for this patient's safety?
A. Approach the patient from the right side and place the call light on the right side
of the bed.
B. Place the call light, meal tray, and personal items on the patient's left side; verbally
cue the patient to scan the left environment.
C. Restrain the patient's left arm to prevent injury from uncontrolled movement.
D. Administer sedative medications to reduce agitation from spatial disorientation.
Correct Answer: B
B addresses unilateral neglect through environmental modification and
compensatory strategies—placing essential items on the affected side with verbal
cueing promotes left-sided scanning and independence. A reinforces the neglect by
accommodating it. C is inappropriate restraint. D sedates rather than rehabilitates.
,Question 4
A patient is admitted following a generalized tonic-clonic seizure lasting 4 minutes.
The seizure has stopped, and the patient is now unresponsive with gradual return of
respirations. Which nursing action is PRIORITY during the post-ictal phase?
A. Immediately administer the next scheduled dose of antiepileptic medication.
B. Maintain airway patency, position in side-lying recovery position, monitor oxygen
saturation, and allow gradual awakening.
C. Insert an oropharyngeal airway to prevent tongue biting.
D. Restrain the patient to prevent injury during potential seizure recurrence.
Correct Answer: B
B prioritizes airway management and safe positioning during the post-ictal phase
when the patient is recovering from respiratory depression and altered
consciousness. A is not emergent—medication timing follows orders. C is
contraindicated in a patient with gradual return of consciousness (risk of triggering
gag reflex and vomiting). D is never appropriate for seizure management.
Question 5
A patient with a history of epilepsy is prescribed phenytoin (Dilantin). Which patient
teaching point is ESSENTIAL for long-term adherence and safety?
A. "Take the medication only when you feel a seizure coming on."
B. "Report any gum swelling, bleeding, or overgrowth to your dentist and healthcare
provider immediately."
C. "You can stop the medication once you have been seizure-free for 3 months."
D. "This medication is safe to take during pregnancy without any risks."
Correct Answer: B
, B addresses phenytoin's well-documented adverse effect of gingival hyperplasia
(gum overgrowth), which requires dental monitoring and good oral hygiene. A is
incorrect—phenytoin is maintenance therapy, not abortive. C is dangerous—
antiepileptics require gradual tapering under medical supervision. D is false—
phenytoin is teratogenic (fetal hydantoin syndrome).
Question 6
A patient is admitted in status epilepticus. IV lorazepam has been administered
without seizure cessation. Which medication should the nurse anticipate as the NEXT
line of therapy?
A. Oral phenytoin loading dose.
B. IV fosphenytoin or phenytoin loading dose.
C. IM diazepam.
D. Oral levetiracetam.
Correct Answer: B
B is correct because IV fosphenytoin (or phenytoin) is the second-line agent for
status epilepticus after benzodiazepine failure, providing longer-acting seizure
control. A and D are oral routes inappropriate for ongoing seizures. C is IM
administration—diazepam is poorly absorbed IM and status epilepticus requires IV
access.
Question 7
A patient with traumatic brain injury is being monitored for increased intracranial
pressure (ICP). The nurse observes the following vital signs: BP 180/55 mmHg, HR 52
bpm, respiratory pattern irregular with periods of apnea. Which clinical manifestation
is the nurse observing?
A. Normal compensatory response to brain injury.
Galen College of Nursing | 100% Correct | Med Surg Test |
Pass Guaranteed - A+ Graded
Section 1: Neurologic Disorders - Stroke, Seizures, Head Injury,
Increased ICP (Q1-20)
Question 1
A 68-year-old male is admitted with sudden onset right-sided hemiparesis, aphasia,
and a National Institutes of Health Stroke Scale (NIHSS) score of 18. CT scan shows
no hemorrhage. The patient's last known well time was 2.5 hours ago. Vital signs are
stable. Which intervention is the nurse's HIGHEST priority?
A. Initiate aspirin 325 mg orally immediately.
B. Prepare the patient for possible administration of alteplase (tPA) after confirming
eligibility criteria.
C. Insert a nasogastric tube for enteral feeding due to aspiration risk.
D. Apply bilateral wrist restraints to prevent falls from hemiparesis.
Correct Answer: B
B is correct because the patient meets critical tPA criteria: ischemic stroke confirmed
by CT (no hemorrhage), NIHSS score indicating moderate-severe deficit (appropriate
for intervention), and within the 3-4.5 hour therapeutic window. Aspirin is
contraindicated within 24 hours of tPA. NG tube insertion is premature without
swallowing assessment. Restraints are inappropriate and violate patient rights.
Question 2
,A nurse is caring for a patient 24 hours post-tPA administration for ischemic stroke.
Which assessment finding requires IMMEDIATE notification of the healthcare
provider?
A. Blood pressure 148/92 mmHg.
B. Sudden severe headache with decreased level of consciousness.
C. Mild ecchymosis at the IV insertion site.
D. Temperature 99.1°F (37.3°C).
Correct Answer: B
B indicates potential hemorrhagic transformation post-tPA—the most feared
complication requiring immediate provider notification and likely emergent CT
imaging. A represents mild post-stroke hypertension manageable with ordered
antihypertensives. C is expected minor bleeding from thrombolytic therapy. D is low-
grade fever without clinical significance.
Question 3
A patient with a right-hemispheric stroke exhibits left-sided unilateral neglect. Which
nursing intervention is MOST appropriate for this patient's safety?
A. Approach the patient from the right side and place the call light on the right side
of the bed.
B. Place the call light, meal tray, and personal items on the patient's left side; verbally
cue the patient to scan the left environment.
C. Restrain the patient's left arm to prevent injury from uncontrolled movement.
D. Administer sedative medications to reduce agitation from spatial disorientation.
Correct Answer: B
B addresses unilateral neglect through environmental modification and
compensatory strategies—placing essential items on the affected side with verbal
cueing promotes left-sided scanning and independence. A reinforces the neglect by
accommodating it. C is inappropriate restraint. D sedates rather than rehabilitates.
,Question 4
A patient is admitted following a generalized tonic-clonic seizure lasting 4 minutes.
The seizure has stopped, and the patient is now unresponsive with gradual return of
respirations. Which nursing action is PRIORITY during the post-ictal phase?
A. Immediately administer the next scheduled dose of antiepileptic medication.
B. Maintain airway patency, position in side-lying recovery position, monitor oxygen
saturation, and allow gradual awakening.
C. Insert an oropharyngeal airway to prevent tongue biting.
D. Restrain the patient to prevent injury during potential seizure recurrence.
Correct Answer: B
B prioritizes airway management and safe positioning during the post-ictal phase
when the patient is recovering from respiratory depression and altered
consciousness. A is not emergent—medication timing follows orders. C is
contraindicated in a patient with gradual return of consciousness (risk of triggering
gag reflex and vomiting). D is never appropriate for seizure management.
Question 5
A patient with a history of epilepsy is prescribed phenytoin (Dilantin). Which patient
teaching point is ESSENTIAL for long-term adherence and safety?
A. "Take the medication only when you feel a seizure coming on."
B. "Report any gum swelling, bleeding, or overgrowth to your dentist and healthcare
provider immediately."
C. "You can stop the medication once you have been seizure-free for 3 months."
D. "This medication is safe to take during pregnancy without any risks."
Correct Answer: B
, B addresses phenytoin's well-documented adverse effect of gingival hyperplasia
(gum overgrowth), which requires dental monitoring and good oral hygiene. A is
incorrect—phenytoin is maintenance therapy, not abortive. C is dangerous—
antiepileptics require gradual tapering under medical supervision. D is false—
phenytoin is teratogenic (fetal hydantoin syndrome).
Question 6
A patient is admitted in status epilepticus. IV lorazepam has been administered
without seizure cessation. Which medication should the nurse anticipate as the NEXT
line of therapy?
A. Oral phenytoin loading dose.
B. IV fosphenytoin or phenytoin loading dose.
C. IM diazepam.
D. Oral levetiracetam.
Correct Answer: B
B is correct because IV fosphenytoin (or phenytoin) is the second-line agent for
status epilepticus after benzodiazepine failure, providing longer-acting seizure
control. A and D are oral routes inappropriate for ongoing seizures. C is IM
administration—diazepam is poorly absorbed IM and status epilepticus requires IV
access.
Question 7
A patient with traumatic brain injury is being monitored for increased intracranial
pressure (ICP). The nurse observes the following vital signs: BP 180/55 mmHg, HR 52
bpm, respiratory pattern irregular with periods of apnea. Which clinical manifestation
is the nurse observing?
A. Normal compensatory response to brain injury.
