NUR 254 MEDICAL-SURGICAL NURSING II EXAM 4
2026/2027 | Galen College of Nursing | 100% Correct |
Pass Guaranteed - A+ Graded
Section 1: Neurological Disorders (Stroke, Seizures, Head
Trauma, Meningitis) (Q1-15)
Q1. A 68-year-old male is admitted to the emergency department with sudden onset
of right-sided weakness, slurred speech, and a severe headache. His blood pressure
is 220/110 mmHg. CT scan reveals a hyperdense lesion in the left basal ganglia. The
nurse recognizes this as which type of stroke?
A. Ischemic stroke due to thrombosis
B. Hemorrhagic stroke due to ruptured cerebral artery
C. Transient ischemic attack (TIA)
D. Embolic stroke from atrial fibrillation
B. Hemorrhagic stroke due to ruptured cerebral artery [CORRECT]
Rationale: The hyperdense appearance on CT indicates acute blood (hemorrhage),
and the severe headache with marked hypertension are classic for hemorrhagic
stroke. Ischemic strokes appear hypodense on CT; TIAs resolve within 24 hours
without imaging evidence; embolic strokes typically present with atrial fibrillation
history and ischemic imaging findings.
Correct Answer: B
Q2. A nurse is caring for a patient 2 hours post-thrombolytic therapy (tPA) for an
ischemic stroke. Which assessment finding requires immediate intervention?
A. Blood pressure 160/92 mmHg
B. Mild headache rated 3/10
,C. Sudden decline in Glasgow Coma Scale from 14 to 9
D. Slight nausea after eating
C. Sudden decline in Glasgow Coma Scale from 14 to 9 [CORRECT]
Rationale: A 5-point drop in GCS indicates neurological deterioration and possible
intracranial hemorrhage—a life-threatening complication of thrombolytic therapy
requiring immediate physician notification and CT scan. Mild headache, slight
nausea, and moderately elevated BP are expected or manageable post-tPA findings.
Correct Answer: C
Q3. The nurse is preparing a care plan for a patient with increased intracranial
pressure (ICP). Which intervention is PRIORITY?
A. Maintain head of bed at 15-30 degrees
B. Administer osmotic diuretics (mannitol) as ordered
C. Ensure neck is in neutral alignment without flexion or rotation
D. Cluster nursing activities to minimize stimulation
C. Ensure neck is in neutral alignment without flexion or rotation [CORRECT]
Rationale: Neck flexion or rotation can compress the jugular veins, impairing venous
drainage from the brain and acutely worsening ICP. While all options are appropriate
ICP management strategies, maintaining neutral neck alignment is foundational and
prevents immediate ICP spikes. Options A, B, and D are important but secondary to
ensuring adequate cerebral venous outflow.
Correct Answer: C
Q4. A patient with traumatic brain injury has an external ventricular drain (EVD) in
place. The nurse notes the drainage chamber is positioned 15 cm above the tragus of
the ear. Which statement is correct?
A. The EVD should be raised to 25 cm to increase drainage
B. The EVD is correctly positioned to maintain normal ICP
,C. The EVD should be lowered to 5 cm to promote drainage
D. The EVD positioning is irrelevant to ICP management
B. The EVD is correctly positioned to maintain normal ICP [CORRECT]
Rationale: EVDs are typically set at 10-20 cm above the tragus (or foramen of Monro)
to maintain ICP at normal levels (0-15 mmHg). Raising the chamber decreases
drainage but protects against overdrainage; lowering increases drainage risk. Option
A would reduce drainage; Option C risks overdrainage and herniation; Option D is
dangerously incorrect.
Correct Answer: B
Q5. A patient with a seizure disorder is admitted after a generalized tonic-clonic
seizure lasting 4 minutes. Which medication is the FIRST-LINE rescue therapy for
prolonged seizures?
A. Phenytoin (Dilantin)
B. Lorazepam (Ativan)
C. Levetiracetam (Keppra)
D. Valproic acid (Depakote)
B. Lorazepam (Ativan) [CORRECT]
Rationale: Benzodiazepines (lorazepam, diazepam) are first-line for acute seizure
termination due to rapid GABA enhancement. Phenytoin and levetiracetam are
maintenance antiepileptics; valproic acid is broad-spectrum maintenance therapy.
Rescue therapy requires rapid onset, which benzodiazepines provide.
Correct Answer: B
Q6. The nurse is caring for a patient post-craniotomy for subdural hematoma
evacuation. Which finding requires the MOST immediate action?
A. Temperature 38.2°C (100.8°F)
B. Urine output 40 mL/hour
, C. Decorticate posturing to painful stimulus
D. Clear drainage from the nasal passages
D. Clear drainage from the nasal passages [CORRECT]
Rationale: Clear rhinorrhea post-craniotomy suggests cerebrospinal fluid (CSF) leak
from a dural tear, risking meningitis and requiring immediate neurosurgical
evaluation. Decorticate posturing (Option C) is concerning but expected with severe
brain injury; fever (Option A) and low urine output (Option B) require monitoring but
are less immediately threatening than a CSF leak.
Correct Answer: D
Q7. A patient with bacterial meningitis is receiving antibiotic therapy. Which nursing
intervention is ESSENTIAL to prevent complications?
A. Maintain the patient in Trendelenburg position
B. Implement droplet precautions for 24 hours after antibiotics initiated
C. Restrict all visitors to prevent overstimulation
D. Administer antibiotics via intramuscular route only
B. Implement droplet precautions for 24 hours after antibiotics initiated
[CORRECT]
Rationale: Bacterial meningitis (especially meningococcal) requires droplet
precautions until 24 hours of effective antibiotic therapy is completed. Trendelenburg
position (Option A) increases ICP; visitor restriction (Option C) is unnecessary after
precautions are in place; IV antibiotics (not IM) are required for CNS penetration.
Correct Answer: B
Q8. A patient with a traumatic brain injury opens eyes to painful stimulus, makes
incomprehensible sounds, and withdraws from painful stimulus. What is the Glasgow
Coma Scale (GCS) score?
2026/2027 | Galen College of Nursing | 100% Correct |
Pass Guaranteed - A+ Graded
Section 1: Neurological Disorders (Stroke, Seizures, Head
Trauma, Meningitis) (Q1-15)
Q1. A 68-year-old male is admitted to the emergency department with sudden onset
of right-sided weakness, slurred speech, and a severe headache. His blood pressure
is 220/110 mmHg. CT scan reveals a hyperdense lesion in the left basal ganglia. The
nurse recognizes this as which type of stroke?
A. Ischemic stroke due to thrombosis
B. Hemorrhagic stroke due to ruptured cerebral artery
C. Transient ischemic attack (TIA)
D. Embolic stroke from atrial fibrillation
B. Hemorrhagic stroke due to ruptured cerebral artery [CORRECT]
Rationale: The hyperdense appearance on CT indicates acute blood (hemorrhage),
and the severe headache with marked hypertension are classic for hemorrhagic
stroke. Ischemic strokes appear hypodense on CT; TIAs resolve within 24 hours
without imaging evidence; embolic strokes typically present with atrial fibrillation
history and ischemic imaging findings.
Correct Answer: B
Q2. A nurse is caring for a patient 2 hours post-thrombolytic therapy (tPA) for an
ischemic stroke. Which assessment finding requires immediate intervention?
A. Blood pressure 160/92 mmHg
B. Mild headache rated 3/10
,C. Sudden decline in Glasgow Coma Scale from 14 to 9
D. Slight nausea after eating
C. Sudden decline in Glasgow Coma Scale from 14 to 9 [CORRECT]
Rationale: A 5-point drop in GCS indicates neurological deterioration and possible
intracranial hemorrhage—a life-threatening complication of thrombolytic therapy
requiring immediate physician notification and CT scan. Mild headache, slight
nausea, and moderately elevated BP are expected or manageable post-tPA findings.
Correct Answer: C
Q3. The nurse is preparing a care plan for a patient with increased intracranial
pressure (ICP). Which intervention is PRIORITY?
A. Maintain head of bed at 15-30 degrees
B. Administer osmotic diuretics (mannitol) as ordered
C. Ensure neck is in neutral alignment without flexion or rotation
D. Cluster nursing activities to minimize stimulation
C. Ensure neck is in neutral alignment without flexion or rotation [CORRECT]
Rationale: Neck flexion or rotation can compress the jugular veins, impairing venous
drainage from the brain and acutely worsening ICP. While all options are appropriate
ICP management strategies, maintaining neutral neck alignment is foundational and
prevents immediate ICP spikes. Options A, B, and D are important but secondary to
ensuring adequate cerebral venous outflow.
Correct Answer: C
Q4. A patient with traumatic brain injury has an external ventricular drain (EVD) in
place. The nurse notes the drainage chamber is positioned 15 cm above the tragus of
the ear. Which statement is correct?
A. The EVD should be raised to 25 cm to increase drainage
B. The EVD is correctly positioned to maintain normal ICP
,C. The EVD should be lowered to 5 cm to promote drainage
D. The EVD positioning is irrelevant to ICP management
B. The EVD is correctly positioned to maintain normal ICP [CORRECT]
Rationale: EVDs are typically set at 10-20 cm above the tragus (or foramen of Monro)
to maintain ICP at normal levels (0-15 mmHg). Raising the chamber decreases
drainage but protects against overdrainage; lowering increases drainage risk. Option
A would reduce drainage; Option C risks overdrainage and herniation; Option D is
dangerously incorrect.
Correct Answer: B
Q5. A patient with a seizure disorder is admitted after a generalized tonic-clonic
seizure lasting 4 minutes. Which medication is the FIRST-LINE rescue therapy for
prolonged seizures?
A. Phenytoin (Dilantin)
B. Lorazepam (Ativan)
C. Levetiracetam (Keppra)
D. Valproic acid (Depakote)
B. Lorazepam (Ativan) [CORRECT]
Rationale: Benzodiazepines (lorazepam, diazepam) are first-line for acute seizure
termination due to rapid GABA enhancement. Phenytoin and levetiracetam are
maintenance antiepileptics; valproic acid is broad-spectrum maintenance therapy.
Rescue therapy requires rapid onset, which benzodiazepines provide.
Correct Answer: B
Q6. The nurse is caring for a patient post-craniotomy for subdural hematoma
evacuation. Which finding requires the MOST immediate action?
A. Temperature 38.2°C (100.8°F)
B. Urine output 40 mL/hour
, C. Decorticate posturing to painful stimulus
D. Clear drainage from the nasal passages
D. Clear drainage from the nasal passages [CORRECT]
Rationale: Clear rhinorrhea post-craniotomy suggests cerebrospinal fluid (CSF) leak
from a dural tear, risking meningitis and requiring immediate neurosurgical
evaluation. Decorticate posturing (Option C) is concerning but expected with severe
brain injury; fever (Option A) and low urine output (Option B) require monitoring but
are less immediately threatening than a CSF leak.
Correct Answer: D
Q7. A patient with bacterial meningitis is receiving antibiotic therapy. Which nursing
intervention is ESSENTIAL to prevent complications?
A. Maintain the patient in Trendelenburg position
B. Implement droplet precautions for 24 hours after antibiotics initiated
C. Restrict all visitors to prevent overstimulation
D. Administer antibiotics via intramuscular route only
B. Implement droplet precautions for 24 hours after antibiotics initiated
[CORRECT]
Rationale: Bacterial meningitis (especially meningococcal) requires droplet
precautions until 24 hours of effective antibiotic therapy is completed. Trendelenburg
position (Option A) increases ICP; visitor restriction (Option C) is unnecessary after
precautions are in place; IV antibiotics (not IM) are required for CNS penetration.
Correct Answer: B
Q8. A patient with a traumatic brain injury opens eyes to painful stimulus, makes
incomprehensible sounds, and withdraws from painful stimulus. What is the Glasgow
Coma Scale (GCS) score?
