NUR 170 Exam 4: Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is monitoring a client who has a head injury and is at risk for increased intracranial pressure (ICP).
Which of the following findings should the nurse identify as the earliest indicator of neurological
deterioration?
A. Decrease in systolic blood pressure
B. Bilateral dilated and fixed pupils
C. A change in the level of consciousness
D. The presence of a Babinski reflex
Correct Answer: C
Rationale: The level of consciousness is the most sensitive indicator of neurological status changes in a
patient. Early signs of increased ICP often include restlessness, agitation, and slight confusion before
physical signs appear. Later signs involve pupillary changes and hemodynamic instability known as
Cushing’s triad. Nurses must perform frequent neuro checks to detect these subtle changes immediately
to ensure safety. Prompt intervention is necessary to prevent permanent brain damage or brain stem
herniation.
2. A nurse is teaching a client who has systemic lupus erythematosus (SLE) about skin care. Which of the
following instructions should the nurse include?
A. Use a tanning bed to improve skin color
B. Wash the skin with mild soap and pat dry
C. Apply powder to lesions to keep them dry
,D. Spend at least 30 minutes in the sun daily
Correct Answer: B
Rationale: Clients with SLE should be instructed to avoid direct sunlight and wear protective clothing
when outdoors to prevent flares. Photosensitivity is a common trigger for exacerbations of the disease
and can worsen skin lesions. Using mild, non-perfumed soaps helps maintain skin integrity and prevents
further irritation of sensitive areas. Education on stress management and rest is also crucial for managing
systemic inflammatory flare-ups. Sunlight exposure can induce both skin and systemic inflammatory
responses in these patients which must be avoided.
3. A nurse is assessing a client who has a cast on their lower leg. Which of the following findings is a priority
to report to the provider as a possible sign of compartment syndrome?
A. Intense pain that is unrelieved by narcotics
B. Capillary refill of less than 2 seconds
C. Pain that is relieved by elevation
D. The client’s ability to wiggle their toes
Correct Answer: A
Rationale: Pain out of proportion to the injury is the hallmark sign of early compartment syndrome. The
nurse must immediately perform a neurovascular assessment, checking pulses, color, temperature, and
sensation in the limb. Elevation above the heart should actually be avoided as it can decrease arterial
perfusion to the affected area. Compartment syndrome is a medical emergency that requires swift
surgical intervention like a fasciotomy to prevent loss of limb. Early detection through regular monitoring
is the most critical nursing responsibility in post-fracture care.
, 4. A client with Parkinson’s disease is prescribed levodopa/carbidopa. What information should the nurse
include in the medication teaching?
A. Move slowly when rising from a sitting or lying position
B. A high-protein meal increases the absorption of the drug
C. Expect results to be immediate within the first dose
D. Stop the medication immediately if tremors improve
Correct Answer: A
Rationale: Levodopa/carbidopa can cause orthostatic hypotension, increasing the risk for falls in
Parkinson’s patients. Patients should be taught to move slowly when changing positions to allow the
body to adjust. It is also important to note that high-protein meals can actually interfere with the
absorption of the medication. The drug takes several weeks to achieve therapeutic effects and should
never be stopped abruptly. Consistent timing of medication administration is vital to maintain
therapeutic levels and minimize ‘off’ periods.
5. A nurse is caring for a client with Rheumatoid Arthritis (RA). Which characteristic of joint pain is most
typical for this condition?
A. Pain that is worse at the end of the day
B. Morning stiffness lasting more than one hour
C. Pain that is relieved by activity and exercise
D. Asymmetrical joint involvement in large joints
Correct Answer: B
Rationale: Rheumatoid arthritis is a chronic autoimmune disorder that causes systemic inflammation in
the synovial joints. Patients typically experience morning stiffness that lasts for more than an hour and
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is monitoring a client who has a head injury and is at risk for increased intracranial pressure (ICP).
Which of the following findings should the nurse identify as the earliest indicator of neurological
deterioration?
A. Decrease in systolic blood pressure
B. Bilateral dilated and fixed pupils
C. A change in the level of consciousness
D. The presence of a Babinski reflex
Correct Answer: C
Rationale: The level of consciousness is the most sensitive indicator of neurological status changes in a
patient. Early signs of increased ICP often include restlessness, agitation, and slight confusion before
physical signs appear. Later signs involve pupillary changes and hemodynamic instability known as
Cushing’s triad. Nurses must perform frequent neuro checks to detect these subtle changes immediately
to ensure safety. Prompt intervention is necessary to prevent permanent brain damage or brain stem
herniation.
2. A nurse is teaching a client who has systemic lupus erythematosus (SLE) about skin care. Which of the
following instructions should the nurse include?
A. Use a tanning bed to improve skin color
B. Wash the skin with mild soap and pat dry
C. Apply powder to lesions to keep them dry
,D. Spend at least 30 minutes in the sun daily
Correct Answer: B
Rationale: Clients with SLE should be instructed to avoid direct sunlight and wear protective clothing
when outdoors to prevent flares. Photosensitivity is a common trigger for exacerbations of the disease
and can worsen skin lesions. Using mild, non-perfumed soaps helps maintain skin integrity and prevents
further irritation of sensitive areas. Education on stress management and rest is also crucial for managing
systemic inflammatory flare-ups. Sunlight exposure can induce both skin and systemic inflammatory
responses in these patients which must be avoided.
3. A nurse is assessing a client who has a cast on their lower leg. Which of the following findings is a priority
to report to the provider as a possible sign of compartment syndrome?
A. Intense pain that is unrelieved by narcotics
B. Capillary refill of less than 2 seconds
C. Pain that is relieved by elevation
D. The client’s ability to wiggle their toes
Correct Answer: A
Rationale: Pain out of proportion to the injury is the hallmark sign of early compartment syndrome. The
nurse must immediately perform a neurovascular assessment, checking pulses, color, temperature, and
sensation in the limb. Elevation above the heart should actually be avoided as it can decrease arterial
perfusion to the affected area. Compartment syndrome is a medical emergency that requires swift
surgical intervention like a fasciotomy to prevent loss of limb. Early detection through regular monitoring
is the most critical nursing responsibility in post-fracture care.
, 4. A client with Parkinson’s disease is prescribed levodopa/carbidopa. What information should the nurse
include in the medication teaching?
A. Move slowly when rising from a sitting or lying position
B. A high-protein meal increases the absorption of the drug
C. Expect results to be immediate within the first dose
D. Stop the medication immediately if tremors improve
Correct Answer: A
Rationale: Levodopa/carbidopa can cause orthostatic hypotension, increasing the risk for falls in
Parkinson’s patients. Patients should be taught to move slowly when changing positions to allow the
body to adjust. It is also important to note that high-protein meals can actually interfere with the
absorption of the medication. The drug takes several weeks to achieve therapeutic effects and should
never be stopped abruptly. Consistent timing of medication administration is vital to maintain
therapeutic levels and minimize ‘off’ periods.
5. A nurse is caring for a client with Rheumatoid Arthritis (RA). Which characteristic of joint pain is most
typical for this condition?
A. Pain that is worse at the end of the day
B. Morning stiffness lasting more than one hour
C. Pain that is relieved by activity and exercise
D. Asymmetrical joint involvement in large joints
Correct Answer: B
Rationale: Rheumatoid arthritis is a chronic autoimmune disorder that causes systemic inflammation in
the synovial joints. Patients typically experience morning stiffness that lasts for more than an hour and
