NUR242 Medical-Surgical Nursing Exam 4 Question
Bank (Version 2)
150 New Practice Questions with Answers and Rationales
1. A patient with a traumatic brain injury has an ICP of 22 mm Hg and a CPP of 55
mm Hg. Which intervention should the nurse implement first?
A. Administer mannitol as prescribed
B. Elevate the head of the bed to 30 degrees
C. Notify the healthcare provider
D. Increase the rate of IV fluids
Answer: B
Rationale:
2. A patient is exhibiting decerebrate posturing. Which assessment finding would
the nurse observe?
A. Arms flexed, legs extended
B. Arms extended, legs extended
C. Arms flexed, legs flexed
D. Flaccid paralysis on one side
,Answer: B
Rationale:
3. A patient with a left-sided stroke is having difficulty understanding spoken
language but can speak fluently. This is most consistent with:
A. Broca's aphasia
B. Wernicke's aphasia
C. Global aphasia
D. Dysarthria
Answer: B
Rationale:
4. Which medication should the nurse question for a patient with increased ICP?
A. Mannitol
B. Dexamethasone
C. Morphine sulfate
D. Phenytoin
Answer: C
Rationale:
,5. A patient with a seizure disorder is prescribed phenytoin (Dilantin). Which
statement indicates understanding of this medication?
A. "I will take this medication with milk."
B. "I will report any bleeding or bruising to my provider."
C. "I can stop this medication once my seizures stop."
D. "I will take this medication only when I feel a seizure coming."
Answer: B
Rationale:
6. A patient with a spinal cord injury at T6 is complaining of a severe headache,
nasal congestion, and has a blood pressure of 190/110 mm Hg. What is the
priority action?
A. Administer acetaminophen for headache
B. Check for bladder distention or fecal impaction
C. Administer antihypertensive medication
D. Elevate the head of the bed
Answer: B
Rationale:
7. A patient with myasthenia gravis is experiencing a myasthenic crisis. Which
finding is most concerning?
A. Ptosis of the eyelids
B. Difficulty chewing food
C. Respiratory rate of 8 breaths/min
D. Diplopia
, Answer: C
Rationale:
8. The nurse is caring for a patient with Guillain-Barré syndrome. Which
assessment finding would the nurse expect first?
A. Ascending weakness and paresthesia
B. Descending paralysis
C. Hemiplegia
D. Ataxia
Answer: A
Rationale:
9. A patient with multiple sclerosis is started on interferon beta-1a. What is the
most important teaching point?
A. "Take this medication with food to prevent nausea."
B. "Report any signs of depression or suicidal thoughts."
C. "This medication will cure your multiple sclerosis."
D. "You can stop taking this medication during flare-ups."
Answer: B
Rationale:
Bank (Version 2)
150 New Practice Questions with Answers and Rationales
1. A patient with a traumatic brain injury has an ICP of 22 mm Hg and a CPP of 55
mm Hg. Which intervention should the nurse implement first?
A. Administer mannitol as prescribed
B. Elevate the head of the bed to 30 degrees
C. Notify the healthcare provider
D. Increase the rate of IV fluids
Answer: B
Rationale:
2. A patient is exhibiting decerebrate posturing. Which assessment finding would
the nurse observe?
A. Arms flexed, legs extended
B. Arms extended, legs extended
C. Arms flexed, legs flexed
D. Flaccid paralysis on one side
,Answer: B
Rationale:
3. A patient with a left-sided stroke is having difficulty understanding spoken
language but can speak fluently. This is most consistent with:
A. Broca's aphasia
B. Wernicke's aphasia
C. Global aphasia
D. Dysarthria
Answer: B
Rationale:
4. Which medication should the nurse question for a patient with increased ICP?
A. Mannitol
B. Dexamethasone
C. Morphine sulfate
D. Phenytoin
Answer: C
Rationale:
,5. A patient with a seizure disorder is prescribed phenytoin (Dilantin). Which
statement indicates understanding of this medication?
A. "I will take this medication with milk."
B. "I will report any bleeding or bruising to my provider."
C. "I can stop this medication once my seizures stop."
D. "I will take this medication only when I feel a seizure coming."
Answer: B
Rationale:
6. A patient with a spinal cord injury at T6 is complaining of a severe headache,
nasal congestion, and has a blood pressure of 190/110 mm Hg. What is the
priority action?
A. Administer acetaminophen for headache
B. Check for bladder distention or fecal impaction
C. Administer antihypertensive medication
D. Elevate the head of the bed
Answer: B
Rationale:
7. A patient with myasthenia gravis is experiencing a myasthenic crisis. Which
finding is most concerning?
A. Ptosis of the eyelids
B. Difficulty chewing food
C. Respiratory rate of 8 breaths/min
D. Diplopia
, Answer: C
Rationale:
8. The nurse is caring for a patient with Guillain-Barré syndrome. Which
assessment finding would the nurse expect first?
A. Ascending weakness and paresthesia
B. Descending paralysis
C. Hemiplegia
D. Ataxia
Answer: A
Rationale:
9. A patient with multiple sclerosis is started on interferon beta-1a. What is the
most important teaching point?
A. "Take this medication with food to prevent nausea."
B. "Report any signs of depression or suicidal thoughts."
C. "This medication will cure your multiple sclerosis."
D. "You can stop taking this medication during flare-ups."
Answer: B
Rationale:
