NU185/ NU 185 FINAL EXAM: (NEW
2025/ 2026 UPDATE) MEDICAL-
SURGICAL NURSING II REVIEW|
QUESTIONS
### Section 1: Neurological Disorders (Seizures, Head Trauma, Stroke)
**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.
**Answer:** D) Have the fluid checked for glucose.
**Rationale:** Clear fluid drainage from the nose or ears after head trauma suggests a cerebrospinal
fluid (CSF) leak. CSF contains glucose, while mucus does not. Testing the fluid confirms a CSF leak, which
is a life-threatening emergency requiring immediate notification of the healthcare provider. The nurse
should never pack the nose or have the patient blow their nose, as this increases the risk of infection or
increased intracranial pressure .
,---
**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.
**Answer:** A) Support the client's respiratory function.
**Rationale:** The medulla oblongata contains the respiratory center, cardiac center, and vasomotor
center. Damage to the medulla can result in respiratory arrest. While monitoring swallowing (D) is
important to prevent aspiration, maintaining a patent airway and supporting breathing (mechanical
ventilation if needed) is the highest priority to sustain life .
---
**Q3. The nurse is teaching a group of clients about common seizure triggers. Which of the following
should the nurse include? (Select all that apply)**
- A) Sleep deprivation
- B) Alcohol use
- C) High fever
- D) Daily exercise
- E) Hypoglycemia
**Answers:** A, B, C, E
, **Rationale:** Common seizure triggers include sleep deprivation, alcohol use/withdrawal, high fever
(especially in children), and hypoglycemia (low blood sugar). Daily exercise is generally beneficial and
not a trigger unless it leads to hyperventilation or extreme fatigue .
---
**Q4. A client is experiencing status epilepticus. What is the priority nursing action?**
- A) Administer IV phenytoin.
- B) Restrain the patient to prevent injury.
- C) Insert an oral airway.
- D) Turn the client to the side and administer IV lorazepam.
**Answer:** D) Turn the client to the side and administer IV lorazepam.
**Rationale:** Status epilepticus (continuous seizure activity lasting >5 minutes) is a medical
emergency. First-line treatment is IV benzodiazepines (lorazepam or diazepam). Positioning the patient
on their side prevents aspiration of secretions. Restraint is contraindicated, and an oral airway should
only be inserted if the jaw is relaxed to avoid injury .
---
**Q5. A nurse is educating a client about phenytoin (Dilantin). Which statement by the client indicates a
need for further teaching?**
- A) "I will have my blood levels checked regularly."
- B) "I can stop taking the medication once I feel better."
- C) "I should brush and floss regularly to prevent gum issues."
- D) "I'll take my medication at the same time every day."
2025/ 2026 UPDATE) MEDICAL-
SURGICAL NURSING II REVIEW|
QUESTIONS
### Section 1: Neurological Disorders (Seizures, Head Trauma, Stroke)
**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.
**Answer:** D) Have the fluid checked for glucose.
**Rationale:** Clear fluid drainage from the nose or ears after head trauma suggests a cerebrospinal
fluid (CSF) leak. CSF contains glucose, while mucus does not. Testing the fluid confirms a CSF leak, which
is a life-threatening emergency requiring immediate notification of the healthcare provider. The nurse
should never pack the nose or have the patient blow their nose, as this increases the risk of infection or
increased intracranial pressure .
,---
**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.
**Answer:** A) Support the client's respiratory function.
**Rationale:** The medulla oblongata contains the respiratory center, cardiac center, and vasomotor
center. Damage to the medulla can result in respiratory arrest. While monitoring swallowing (D) is
important to prevent aspiration, maintaining a patent airway and supporting breathing (mechanical
ventilation if needed) is the highest priority to sustain life .
---
**Q3. The nurse is teaching a group of clients about common seizure triggers. Which of the following
should the nurse include? (Select all that apply)**
- A) Sleep deprivation
- B) Alcohol use
- C) High fever
- D) Daily exercise
- E) Hypoglycemia
**Answers:** A, B, C, E
, **Rationale:** Common seizure triggers include sleep deprivation, alcohol use/withdrawal, high fever
(especially in children), and hypoglycemia (low blood sugar). Daily exercise is generally beneficial and
not a trigger unless it leads to hyperventilation or extreme fatigue .
---
**Q4. A client is experiencing status epilepticus. What is the priority nursing action?**
- A) Administer IV phenytoin.
- B) Restrain the patient to prevent injury.
- C) Insert an oral airway.
- D) Turn the client to the side and administer IV lorazepam.
**Answer:** D) Turn the client to the side and administer IV lorazepam.
**Rationale:** Status epilepticus (continuous seizure activity lasting >5 minutes) is a medical
emergency. First-line treatment is IV benzodiazepines (lorazepam or diazepam). Positioning the patient
on their side prevents aspiration of secretions. Restraint is contraindicated, and an oral airway should
only be inserted if the jaw is relaxed to avoid injury .
---
**Q5. A nurse is educating a client about phenytoin (Dilantin). Which statement by the client indicates a
need for further teaching?**
- A) "I will have my blood levels checked regularly."
- B) "I can stop taking the medication once I feel better."
- C) "I should brush and floss regularly to prevent gum issues."
- D) "I'll take my medication at the same time every day."
