NUR242 Exam 3 V2 | NUR 242 Med-Surg Exam
Q&A | Galen College of Nursing
────────────────────────────────────
This study guide is intended to provide comprehensive preparation for medical-surgical nursing
assessments related to neurological care, orthopedic nursing, and complex adult medical
conditions. The content reflects practical nursing concepts commonly tested in nursing
examinations.
This version contains realistic exam-style questions designed to strengthen understanding of
adult disease management, nursing assessment findings, and therapeutic interventions. Detailed
expert explanations support concept mastery and practical nursing application.
════════════════════════════════════
The Exam Covers:
• Increased intracranial pressure
• Spinal cord injury nursing care
• Arthritis and joint disorders
• Osteoporosis management
• Blood transfusion nursing care
• Hematologic laboratory interpretation
• Mobility and safety interventions
• Postoperative orthopedic nursing care
════════════════════════════════════
1. A nurse is assessing a client with a head injury. Which of the following findings is the
earliest indicator of increased intracranial pressure (ICP)?
A. Widening pulse pressure
B. Fixed and dilated pupils
C. Change in level of consciousness
,D. Bradycardia
Correct Answer: C
Expert Explanation: A change in the level of consciousness is often the first and most
sensitive sign of increased intracranial pressure. This occurs as a result of impaired
cerebral blood flow and oxygenation to the cerebral cortex. Later signs include Cushing’s
triad, such as bradycardia and widening pulse pressure.
2. Which of the following interventions should the nurse include in the plan of care for a
client at risk for increased ICP?
A. Perform frequent cluster care activities
B. Maintain the head of the bed at 30 degrees
C. Encourage the client to cough and deep breathe
D. Keep the neck in a flexed position
Correct Answer: B
Expert Explanation: Elevating the head of the bed to 30 degrees promotes venous
drainage from the brain and helps reduce intracranial pressure. The nurse should also
maintain the neck in a neutral position to prevent venous obstruction. Activities should be
spaced out rather than clustered to avoid sustained elevations in pressure.
, 3. A nurse is caring for a client with a spinal cord injury at the T4 level. The client reports a
sudden, severe headache and has a blood pressure of 190/100 mmHg. What is the priority
nursing action?
A. Administer an ordered antihypertensive medication
B. Assess the client for bladder distention
C. Lower the head of the bed to a flat position
D. Notify the healthcare provider immediately
Correct Answer: B
Expert Explanation: These symptoms indicate autonomic dysreflexia, which is a medical
emergency common in injuries at or above T6. The most frequent cause is a noxious
stimulus, such as a distended bladder or fecal impaction. The nurse must identify and
remove the stimulus while keeping the patient upright to help lower blood pressure.
4. The nurse is preparing to administer Alendronate to a client with osteoporosis. Which
instruction is essential for this medication?
A. Take the medication with a full meal to avoid GI upset
B. Take the medication with a full glass of water on an empty stomach
C. Lie down for 30 minutes after taking the medication
D. Crush the tablet if the client has difficulty swallowing
Correct Answer: B
Q&A | Galen College of Nursing
────────────────────────────────────
This study guide is intended to provide comprehensive preparation for medical-surgical nursing
assessments related to neurological care, orthopedic nursing, and complex adult medical
conditions. The content reflects practical nursing concepts commonly tested in nursing
examinations.
This version contains realistic exam-style questions designed to strengthen understanding of
adult disease management, nursing assessment findings, and therapeutic interventions. Detailed
expert explanations support concept mastery and practical nursing application.
════════════════════════════════════
The Exam Covers:
• Increased intracranial pressure
• Spinal cord injury nursing care
• Arthritis and joint disorders
• Osteoporosis management
• Blood transfusion nursing care
• Hematologic laboratory interpretation
• Mobility and safety interventions
• Postoperative orthopedic nursing care
════════════════════════════════════
1. A nurse is assessing a client with a head injury. Which of the following findings is the
earliest indicator of increased intracranial pressure (ICP)?
A. Widening pulse pressure
B. Fixed and dilated pupils
C. Change in level of consciousness
,D. Bradycardia
Correct Answer: C
Expert Explanation: A change in the level of consciousness is often the first and most
sensitive sign of increased intracranial pressure. This occurs as a result of impaired
cerebral blood flow and oxygenation to the cerebral cortex. Later signs include Cushing’s
triad, such as bradycardia and widening pulse pressure.
2. Which of the following interventions should the nurse include in the plan of care for a
client at risk for increased ICP?
A. Perform frequent cluster care activities
B. Maintain the head of the bed at 30 degrees
C. Encourage the client to cough and deep breathe
D. Keep the neck in a flexed position
Correct Answer: B
Expert Explanation: Elevating the head of the bed to 30 degrees promotes venous
drainage from the brain and helps reduce intracranial pressure. The nurse should also
maintain the neck in a neutral position to prevent venous obstruction. Activities should be
spaced out rather than clustered to avoid sustained elevations in pressure.
, 3. A nurse is caring for a client with a spinal cord injury at the T4 level. The client reports a
sudden, severe headache and has a blood pressure of 190/100 mmHg. What is the priority
nursing action?
A. Administer an ordered antihypertensive medication
B. Assess the client for bladder distention
C. Lower the head of the bed to a flat position
D. Notify the healthcare provider immediately
Correct Answer: B
Expert Explanation: These symptoms indicate autonomic dysreflexia, which is a medical
emergency common in injuries at or above T6. The most frequent cause is a noxious
stimulus, such as a distended bladder or fecal impaction. The nurse must identify and
remove the stimulus while keeping the patient upright to help lower blood pressure.
4. The nurse is preparing to administer Alendronate to a client with osteoporosis. Which
instruction is essential for this medication?
A. Take the medication with a full meal to avoid GI upset
B. Take the medication with a full glass of water on an empty stomach
C. Lie down for 30 minutes after taking the medication
D. Crush the tablet if the client has difficulty swallowing
Correct Answer: B
