NU 185/ NU 185 FINAL EXAM: (NEW 2025/2026
UPDATE) MEDICAL-SURGICAL NURSING II REVIEW
| QUESTIONS & ANSWERS 1-200
Topic 1: Neurological Disorders (Questions 1-30)
Q1. A client sustains a head trauma after falling from a roof. The nurse observes clear fluid
leaking from the nose. What is the priority action by the nurse?
A. Use a Q-tip to gently clean the nasal passages
B. Pack the nose with nasal packing
C. Have the client blow the nose to clear the passages
D. Have the fluid checked for glucose
☑ Correct Answer: D. Have the fluid checked for glucose
Rationale: Clear fluid leaking from the nose or ears after head trauma may be cerebrospinal
fluid (CSF). CSF contains glucose, while nasal mucus does not. If the glucose test is positive,
notify the healthcare provider immediately because leaking CSF indicates a life-threatening
situation. Do not pack the nose, clean the nasal passages, or have the client blow their nose, as
these actions can increase the risk of infection or further injury .
Q2. A client suffers a stroke located in the medulla. What is the priority action by the nurse?
A. Support the client's respiratory function
B. Assist the client with ambulation
C. Orient the client to surroundings frequently
, D. Monitor the client for swallowing food and fluid
☑ Correct Answer: A. Support the client's respiratory function
Rationale: The medulla contains the respiratory center that regulates breathing. Damage to this
area can compromise the client's ability to breathe independently. While all options are
important nursing interventions, supporting respiratory function is the priority because without
adequate breathing, the client cannot sustain life .
Q3. What do you think can cause people to be more at risk for a bleed?
A. Young age and low blood pressure
B. Age, medications (antiplatelets, anticoagulants, aspirin), alcohol
C. High protein diet and exercise
D. Family history of diabetes
☑ Correct Answer: B. Age, medications (antiplatelets, anticoagulants, aspirin), alcohol
Rationale: Risk factors for bleeding include advanced age (due to vessel fragility), medications
that affect clotting (antiplatelets, anticoagulants, aspirin), and alcohol use (which can impair
platelet function and cause liver damage affecting clotting factors) .
Q4. What do you think the accumulation of blood will do to the inside of the cranium?
A. Decrease intracranial pressure
B. Increase intracranial pressure
C. Have no effect on intracranial pressure
D. Improve cerebral blood flow
☑ Correct Answer: B. Increase intracranial pressure
,Rationale: The cranium is a fixed, enclosed space. Any accumulation of blood (such as from a
subdural or epidural hematoma) increases the volume inside the skull, leading to increased
intracranial pressure (ICP). Elevated ICP can compress brain tissue and lead to herniation .
Q5. The nurse is caring for a client in a coma who has suffered a closed head injury. Which
intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
A. Elevate the head of the bed to 30 degrees
B. Place the client in Trendelenburg position
C. Keep the client in a supine position
D. Lower the head of the bed flat
☑ Correct Answer: A. Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the
head, which helps reduce intracranial pressure. Trendelenburg, supine, and flat positions can
increase ICP by impair venous return .
Q6. A client with chronic alcoholism and late stage cirrhosis has significant damage to
Wernicke's area. What data obtained by the nurse is indicative of this damage?
A. The client is unable to ambulate independently
B. The client does not comprehend written and spoken language but speaks
C. The client has speech impairment, but is able to comprehend language
D. The client's left hand is experiencing paralysis
☑ Correct Answer: B. The client does not comprehend written and spoken language but speaks
, Rationale: Wernicke's area is responsible for language comprehension. Damage to this area
results in receptive aphasia—the client can speak but cannot understand written or spoken
language. Broca's area damage causes expressive aphasia (difficulty speaking but intact
comprehension) .
Q7. A client who sustained head trauma in a motor vehicle crash is determined to have an
increase in intracranial pressure (ICP). What related complications should the nurse be aware
of? (Select all that apply)
A. Brainstem herniation
B. Diabetes insipidus
C. Syndrome of inappropriate antidiuretic hormone (SIADH)
D. Increased urine output
E. Decreased level of consciousness
☑ Correct Answer: A, B, C, D, E (All apply)
Rationale: Increased ICP can lead to multiple complications: brainstem herniation (compression
of brainstem), diabetes insipidus (decreased ADH from pituitary damage), SIADH (excess ADH
secretion), increased urine output (with DI), and decreased level of consciousness (from brain
compression) .
Q8. The nurse observes a client having a generalized tonic-clonic seizure. What is the priority
action by the nurse?
A. Insert a tongue blade between the client's teeth
B. Place the client in the prone position
C. Turn the head to the side
UPDATE) MEDICAL-SURGICAL NURSING II REVIEW
| QUESTIONS & ANSWERS 1-200
Topic 1: Neurological Disorders (Questions 1-30)
Q1. A client sustains a head trauma after falling from a roof. The nurse observes clear fluid
leaking from the nose. What is the priority action by the nurse?
A. Use a Q-tip to gently clean the nasal passages
B. Pack the nose with nasal packing
C. Have the client blow the nose to clear the passages
D. Have the fluid checked for glucose
☑ Correct Answer: D. Have the fluid checked for glucose
Rationale: Clear fluid leaking from the nose or ears after head trauma may be cerebrospinal
fluid (CSF). CSF contains glucose, while nasal mucus does not. If the glucose test is positive,
notify the healthcare provider immediately because leaking CSF indicates a life-threatening
situation. Do not pack the nose, clean the nasal passages, or have the client blow their nose, as
these actions can increase the risk of infection or further injury .
Q2. A client suffers a stroke located in the medulla. What is the priority action by the nurse?
A. Support the client's respiratory function
B. Assist the client with ambulation
C. Orient the client to surroundings frequently
, D. Monitor the client for swallowing food and fluid
☑ Correct Answer: A. Support the client's respiratory function
Rationale: The medulla contains the respiratory center that regulates breathing. Damage to this
area can compromise the client's ability to breathe independently. While all options are
important nursing interventions, supporting respiratory function is the priority because without
adequate breathing, the client cannot sustain life .
Q3. What do you think can cause people to be more at risk for a bleed?
A. Young age and low blood pressure
B. Age, medications (antiplatelets, anticoagulants, aspirin), alcohol
C. High protein diet and exercise
D. Family history of diabetes
☑ Correct Answer: B. Age, medications (antiplatelets, anticoagulants, aspirin), alcohol
Rationale: Risk factors for bleeding include advanced age (due to vessel fragility), medications
that affect clotting (antiplatelets, anticoagulants, aspirin), and alcohol use (which can impair
platelet function and cause liver damage affecting clotting factors) .
Q4. What do you think the accumulation of blood will do to the inside of the cranium?
A. Decrease intracranial pressure
B. Increase intracranial pressure
C. Have no effect on intracranial pressure
D. Improve cerebral blood flow
☑ Correct Answer: B. Increase intracranial pressure
,Rationale: The cranium is a fixed, enclosed space. Any accumulation of blood (such as from a
subdural or epidural hematoma) increases the volume inside the skull, leading to increased
intracranial pressure (ICP). Elevated ICP can compress brain tissue and lead to herniation .
Q5. The nurse is caring for a client in a coma who has suffered a closed head injury. Which
intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
A. Elevate the head of the bed to 30 degrees
B. Place the client in Trendelenburg position
C. Keep the client in a supine position
D. Lower the head of the bed flat
☑ Correct Answer: A. Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the
head, which helps reduce intracranial pressure. Trendelenburg, supine, and flat positions can
increase ICP by impair venous return .
Q6. A client with chronic alcoholism and late stage cirrhosis has significant damage to
Wernicke's area. What data obtained by the nurse is indicative of this damage?
A. The client is unable to ambulate independently
B. The client does not comprehend written and spoken language but speaks
C. The client has speech impairment, but is able to comprehend language
D. The client's left hand is experiencing paralysis
☑ Correct Answer: B. The client does not comprehend written and spoken language but speaks
, Rationale: Wernicke's area is responsible for language comprehension. Damage to this area
results in receptive aphasia—the client can speak but cannot understand written or spoken
language. Broca's area damage causes expressive aphasia (difficulty speaking but intact
comprehension) .
Q7. A client who sustained head trauma in a motor vehicle crash is determined to have an
increase in intracranial pressure (ICP). What related complications should the nurse be aware
of? (Select all that apply)
A. Brainstem herniation
B. Diabetes insipidus
C. Syndrome of inappropriate antidiuretic hormone (SIADH)
D. Increased urine output
E. Decreased level of consciousness
☑ Correct Answer: A, B, C, D, E (All apply)
Rationale: Increased ICP can lead to multiple complications: brainstem herniation (compression
of brainstem), diabetes insipidus (decreased ADH from pituitary damage), SIADH (excess ADH
secretion), increased urine output (with DI), and decreased level of consciousness (from brain
compression) .
Q8. The nurse observes a client having a generalized tonic-clonic seizure. What is the priority
action by the nurse?
A. Insert a tongue blade between the client's teeth
B. Place the client in the prone position
C. Turn the head to the side
