NURS MED SURGE EXAM 2 QUESTIONS WITH
ANSWERS 2023 A+ GUARANTEED SUCCESS
An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury.
The patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment
being given. What action is best for the nurse to take?
a.
Ask the family to stay in the waiting room until the initial assessment is completed.
b.
Allow the family to stay with the patient and briefly explain all procedures to them.
c.
Refer the family members to the hospital counseling service to deal with their
anxiety. d.
Call the family’s pastor or spiritual advisor to take them to the chapel while care is given.
ANS: B
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26.
Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a.
Blood pressure 154/68, pulse 56, respirations 12
b.
Blood pressure 134/72, pulse 90, respirations 32
c.
Blood pressure 148/78, pulse 112, respirations 28
d.
Blood pressure 110/70, pulse 120, respirations 30
ANS: A
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the
arms, the nurse reports the response as
a.
flexion withdrawal.
b.
localization of pain.
c.
decorticate posturing.
d.
decerebrate posturing.
ANS: C
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter
should the nurse monitor to determine the medication’s effectiveness?
a.
Blood pressure
b.
Oxygen saturation
c.
Intracranial pressure
d.
Hemoglobin and hematocrit
ANS: C
, NURS MED SURGE EXAM 2 QUESTIONS WITH
ANSWERS 2023 A+ GUARANTEED SUCCESS
cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
a.
Encourage coughing and deep breathing.
b.
Position the patient with knees and hips flexed.
c.
Keep the head of the bed elevated to 30 degrees.
d.
Cluster nursing interventions to provide rest periods.
ANS: C
10. A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which action will the nurse plan to take?
a.
Administer IV furosemide (Lasix).
b.
Prepare the patient for craniotomy.
c.
Initiate high-dose barbiturate therapy.
d.
Type and crossmatch for blood transfusion.
ANS: B
31. The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which
assessment information requires the most rapid action by the nurse?
a.
The apical pulse is slightly
irregular. b.
The patient complains of a headache.
c.
The patient is more difficult to arouse.
d.
The blood pressure (BP) increases to 140/62 mm Hg.
ANS: C
33. When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency
department (ED), the nurse obtains the following information. Which finding is most important to report to the
health care provider?
a.
The patient takes warfarin (Coumadin)
daily. b.
The patient’s blood pressure is 162/94 mm
Hg. c.
The patient is unable to remember the accident.
d.
The patient complains of a severe dull headache.
ANS: A
2. A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates
that the nurse should consult with the health care provider before giving the prescribed aspirin?
a.
The patient has dysphasia.
b.
The patient has atrial fibrillation.
c.
The patient reports that symptoms began with a severe headache.
, NURS MED SURGE EXAM 2 QUESTIONS WITH
ANSWERS 2023 A+ GUARANTEED SUCCESS
d.
The patient has a history of brief episodes of right-sided hemiplegia.
ANS: C
8. A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours
previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates
preparing the patient for
a.
surgical endarterectomy.
b.
transluminal angioplasty.
c.
intravenous heparin administration.
d.
tissue plasminogen activator (tPA)
infusion. ANS: D
11. When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which
intervention should the nurse include in the plan of care?
a.
Apply an eye patch to the right eye.
b.
Approach the patient from the right side.
c.
Place objects needed on the patient’s left
side. d.
Teach the patient that the left visual deficit will
resolve. ANS: C
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for
feeding and other activities. The nurse observes that when the patient’s wife is visiting, she feeds and dresses him.
Which nursing diagnosis is most appropriate for the patient?
a.
Interrupted family processes related to effects of illness of a family member
b.
Situational low self-esteem related to increasing dependence on spouse for care
c.
Disabled family coping related to inadequate understanding by patient’s spouse
d.
Impaired nutrition: less than body requirements related to hemiplegia and aphasia
ANS: C
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting
in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective
bladder training program?
a.
Limit fluid intake to 1200 mL daily to reduce urine volume.
b.
Assist the patient onto the bedside commode every 2 hours.
c.
Perform intermittent catheterization after each voiding to check for residual urine.
d.
Use an external “condom” catheter to protect the skin and prevent embarrassment.
ANSWERS 2023 A+ GUARANTEED SUCCESS
An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury.
The patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment
being given. What action is best for the nurse to take?
a.
Ask the family to stay in the waiting room until the initial assessment is completed.
b.
Allow the family to stay with the patient and briefly explain all procedures to them.
c.
Refer the family members to the hospital counseling service to deal with their
anxiety. d.
Call the family’s pastor or spiritual advisor to take them to the chapel while care is given.
ANS: B
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26.
Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a.
Blood pressure 154/68, pulse 56, respirations 12
b.
Blood pressure 134/72, pulse 90, respirations 32
c.
Blood pressure 148/78, pulse 112, respirations 28
d.
Blood pressure 110/70, pulse 120, respirations 30
ANS: A
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the
arms, the nurse reports the response as
a.
flexion withdrawal.
b.
localization of pain.
c.
decorticate posturing.
d.
decerebrate posturing.
ANS: C
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter
should the nurse monitor to determine the medication’s effectiveness?
a.
Blood pressure
b.
Oxygen saturation
c.
Intracranial pressure
d.
Hemoglobin and hematocrit
ANS: C
, NURS MED SURGE EXAM 2 QUESTIONS WITH
ANSWERS 2023 A+ GUARANTEED SUCCESS
cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
a.
Encourage coughing and deep breathing.
b.
Position the patient with knees and hips flexed.
c.
Keep the head of the bed elevated to 30 degrees.
d.
Cluster nursing interventions to provide rest periods.
ANS: C
10. A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which action will the nurse plan to take?
a.
Administer IV furosemide (Lasix).
b.
Prepare the patient for craniotomy.
c.
Initiate high-dose barbiturate therapy.
d.
Type and crossmatch for blood transfusion.
ANS: B
31. The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which
assessment information requires the most rapid action by the nurse?
a.
The apical pulse is slightly
irregular. b.
The patient complains of a headache.
c.
The patient is more difficult to arouse.
d.
The blood pressure (BP) increases to 140/62 mm Hg.
ANS: C
33. When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency
department (ED), the nurse obtains the following information. Which finding is most important to report to the
health care provider?
a.
The patient takes warfarin (Coumadin)
daily. b.
The patient’s blood pressure is 162/94 mm
Hg. c.
The patient is unable to remember the accident.
d.
The patient complains of a severe dull headache.
ANS: A
2. A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates
that the nurse should consult with the health care provider before giving the prescribed aspirin?
a.
The patient has dysphasia.
b.
The patient has atrial fibrillation.
c.
The patient reports that symptoms began with a severe headache.
, NURS MED SURGE EXAM 2 QUESTIONS WITH
ANSWERS 2023 A+ GUARANTEED SUCCESS
d.
The patient has a history of brief episodes of right-sided hemiplegia.
ANS: C
8. A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours
previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates
preparing the patient for
a.
surgical endarterectomy.
b.
transluminal angioplasty.
c.
intravenous heparin administration.
d.
tissue plasminogen activator (tPA)
infusion. ANS: D
11. When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which
intervention should the nurse include in the plan of care?
a.
Apply an eye patch to the right eye.
b.
Approach the patient from the right side.
c.
Place objects needed on the patient’s left
side. d.
Teach the patient that the left visual deficit will
resolve. ANS: C
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for
feeding and other activities. The nurse observes that when the patient’s wife is visiting, she feeds and dresses him.
Which nursing diagnosis is most appropriate for the patient?
a.
Interrupted family processes related to effects of illness of a family member
b.
Situational low self-esteem related to increasing dependence on spouse for care
c.
Disabled family coping related to inadequate understanding by patient’s spouse
d.
Impaired nutrition: less than body requirements related to hemiplegia and aphasia
ANS: C
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting
in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective
bladder training program?
a.
Limit fluid intake to 1200 mL daily to reduce urine volume.
b.
Assist the patient onto the bedside commode every 2 hours.
c.
Perform intermittent catheterization after each voiding to check for residual urine.
d.
Use an external “condom” catheter to protect the skin and prevent embarrassment.
