NURS 120 – Introduction to Medical Surgical
Nursing (WCU) | Quiz 5 | 2026/2027 Update |
Verified Questions & Answers
1–10 Neurological Assessment & Diagnostics
Q1. The nurse performs a quick bedside neurological assessment using the Glasgow Coma
Scale. The patient opens eyes to painful stimuli, makes incomprehensible sounds, and localizes
pain. GCS score is:
A) 6 B) 8 C) 10 D) 12
Answer: C (10) – Eye 2 + Verbal 2 + Motor 6 = 10
Q2. Which finding is considered an EARLY sign of increased intracranial pressure?
A) Widened pulse pressure B) Bradycardia C) Fixed unilateral pupil D) Decorticate
posturing
Answer: A – Early Cushing triad = widening pulse pressure, bradycardia, irregular respirations
Q3. During a complete cranial nerve assessment, the nurse asks the patient to shrug shoulders
against resistance. This tests cranial nerve:
A) CN VII B) CN IX C) CN XI D) CN XII
Answer: C – CN XI (spinal accessory) – trapezius and sternocleidomastoid
Q4. A positive Babinski reflex in an adult is:
A) Normal B) Indicates upper motor neuron lesion C) Indicates lower motor neuron
lesion D) Always benign
Answer: B – Pathologic in adults >2 years (upper motor neuron issue)
Q5. The diagnostic test of choice to rule out subarachnoid hemorrhage is:
A) Non-contrast CT head B) MRI brain C) Lumbar puncture D) Cerebral angiogram
Answer: A – 2026 guidelines: Non-contrast CT within 6 hours is >98% sensitive for SAH
Q6. Normal intracranial pressure (ICP) range in adults is:
A) 0–15 mmHg B) 20–30 mmHg C) 30–40 mmHg D) <5 mmHg
Answer: A – Normal 0–15 mmHg (measured in mmHg via ventriculostomy or bolt)
, Q7. Cerebral perfusion pressure (CPP) is calculated as:
A) MAP – ICP B) SBP – ICP C) MAP – CVP D) SBP – DBP
Answer: A – Goal CPP 60–70 mmHg in neurocritical, 2026 neurocritical care guidelines
Q8. The nurse notes decorticate posturing (arms flexed, legs extended). This indicates damage
at the level of the:
A) Cortex or midbrain B) Brainstem C) Spinal cord D) Cerebellum
Answer: A – Decorticate = above red nucleus (midbrain); decerebrate = below
Q9. A patient with suspected meningitis is scheduled for lumbar puncture. The nurse should
position the patient:
A) Supine with head of bed 30° B) Lateral recumbent, fetal position C) Prone D) Sitting
upright
Answer: B – Fetal position opens spinal processes for needle entry
Q10. The earliest and most reliable sign of declining neurological status is:
A) Change in level of consciousness B) Pupil changes C) Seizure activity D) Hypertension
Answer: A – LOC is the most sensitive indicator of neurological deterioration
11–25 Stroke (Ischemic & Hemorrhagic)
Q11. The 2026 AHA/ASA guideline time goal for door-to-needle with IV alteplase in acute
ischemic stroke is:
A) 30 minutes B) 45 minutes C) 60 minutes D) 90 minutes
Answer: B – Door-to-needle ≤45 minutes (updated 2026)
Q12. A patient arrives 3.5 hours after onset of right-sided weakness and aphasia. BP is 190/110.
The FIRST action is:
A) Give IV alteplase B) Lower BP with labetalol C) Obtain non-contrast CT D) Give aspirin
325 mg
Answer: C – CT first to rule out hemorrhage before any treatment
Q13. The patient is receiving IV alteplase. Which finding requires immediate discontinuation of
the infusion?
A) Gum bleeding B) Sudden severe headache C) BP 185/110 D) Nausea
Answer: B – Sudden severe headache may indicate intracranial hemorrhage
Q14. The hallmark difference between ischemic and hemorrhagic stroke on non-contrast CT is:
A) Hyperdense area (hemorrhagic) vs. hypodense or normal early (ischemic)
B) Midline shift in ischemic
Nursing (WCU) | Quiz 5 | 2026/2027 Update |
Verified Questions & Answers
1–10 Neurological Assessment & Diagnostics
Q1. The nurse performs a quick bedside neurological assessment using the Glasgow Coma
Scale. The patient opens eyes to painful stimuli, makes incomprehensible sounds, and localizes
pain. GCS score is:
A) 6 B) 8 C) 10 D) 12
Answer: C (10) – Eye 2 + Verbal 2 + Motor 6 = 10
Q2. Which finding is considered an EARLY sign of increased intracranial pressure?
A) Widened pulse pressure B) Bradycardia C) Fixed unilateral pupil D) Decorticate
posturing
Answer: A – Early Cushing triad = widening pulse pressure, bradycardia, irregular respirations
Q3. During a complete cranial nerve assessment, the nurse asks the patient to shrug shoulders
against resistance. This tests cranial nerve:
A) CN VII B) CN IX C) CN XI D) CN XII
Answer: C – CN XI (spinal accessory) – trapezius and sternocleidomastoid
Q4. A positive Babinski reflex in an adult is:
A) Normal B) Indicates upper motor neuron lesion C) Indicates lower motor neuron
lesion D) Always benign
Answer: B – Pathologic in adults >2 years (upper motor neuron issue)
Q5. The diagnostic test of choice to rule out subarachnoid hemorrhage is:
A) Non-contrast CT head B) MRI brain C) Lumbar puncture D) Cerebral angiogram
Answer: A – 2026 guidelines: Non-contrast CT within 6 hours is >98% sensitive for SAH
Q6. Normal intracranial pressure (ICP) range in adults is:
A) 0–15 mmHg B) 20–30 mmHg C) 30–40 mmHg D) <5 mmHg
Answer: A – Normal 0–15 mmHg (measured in mmHg via ventriculostomy or bolt)
, Q7. Cerebral perfusion pressure (CPP) is calculated as:
A) MAP – ICP B) SBP – ICP C) MAP – CVP D) SBP – DBP
Answer: A – Goal CPP 60–70 mmHg in neurocritical, 2026 neurocritical care guidelines
Q8. The nurse notes decorticate posturing (arms flexed, legs extended). This indicates damage
at the level of the:
A) Cortex or midbrain B) Brainstem C) Spinal cord D) Cerebellum
Answer: A – Decorticate = above red nucleus (midbrain); decerebrate = below
Q9. A patient with suspected meningitis is scheduled for lumbar puncture. The nurse should
position the patient:
A) Supine with head of bed 30° B) Lateral recumbent, fetal position C) Prone D) Sitting
upright
Answer: B – Fetal position opens spinal processes for needle entry
Q10. The earliest and most reliable sign of declining neurological status is:
A) Change in level of consciousness B) Pupil changes C) Seizure activity D) Hypertension
Answer: A – LOC is the most sensitive indicator of neurological deterioration
11–25 Stroke (Ischemic & Hemorrhagic)
Q11. The 2026 AHA/ASA guideline time goal for door-to-needle with IV alteplase in acute
ischemic stroke is:
A) 30 minutes B) 45 minutes C) 60 minutes D) 90 minutes
Answer: B – Door-to-needle ≤45 minutes (updated 2026)
Q12. A patient arrives 3.5 hours after onset of right-sided weakness and aphasia. BP is 190/110.
The FIRST action is:
A) Give IV alteplase B) Lower BP with labetalol C) Obtain non-contrast CT D) Give aspirin
325 mg
Answer: C – CT first to rule out hemorrhage before any treatment
Q13. The patient is receiving IV alteplase. Which finding requires immediate discontinuation of
the infusion?
A) Gum bleeding B) Sudden severe headache C) BP 185/110 D) Nausea
Answer: B – Sudden severe headache may indicate intracranial hemorrhage
Q14. The hallmark difference between ischemic and hemorrhagic stroke on non-contrast CT is:
A) Hyperdense area (hemorrhagic) vs. hypodense or normal early (ischemic)
B) Midline shift in ischemic
