NUR209 Medical Surgical Nursing II EXAM 1
REVIEW - Fortis College 2026/2027 | Neurological,
GI/Hepatobiliary, Endocrine | Grade-A Focus
SYSTEM 1 – NEUROLOGICAL NURSING (Q 1-15)
Q1
55-y/o, ischemic stroke 4 h ago; sudden slurred speech, R-sided weakness. Most
immediate action?
A. Repeat neuro check
B. Notify provider immediately
C. Reassure patient
D. Give aspirin
Verified Answer: B
Rationale: Sudden neuro change = emergency (possible hemorrhage, extension);
provider must be notified STAT for CT/CTA, possible tPA/bleed management.
Reassessment (A) follows notification.
Q 2 (SATA)
Patient at risk for ↑ ICP. Which interventions included? (Select all)
A. Head of bed 30-45°
,B. Minimize suctioning
C. Administer stool softeners
D. Space activities
E. Encourage vigorous cough
Verified Answers: A, B, C, D
Rationale: Elevate HOB 30-45° (↓ venous pressure), avoid suction stimulus, prevent
Valsalva (stool softeners), space care (↓ CO₂ spikes). Vigorous cough (E) ↑ ICP –
incorrect.
Q3
Acute ischemic stroke; last known normal 2 h ago. tPA inclusion criterion:
A. SBP 180 mmHg on 2 readings
B. INR 1.5
C. CT shows no hemorrhage
D. Platelet 80 k
Verified Answer: C
Rationale: Door-to-needle ≤ 4.5 h, non-contrast CT must rule out bleed (AHA 2026). SBP
must be ≤ 185/110, INR ≤ 1.7, platelets ≥ 100 k.
Q4
Post-tPA infusion; which assessment q 15 min × 2 h?
, A. Neuro exam & BP
B. Temperature only
C. Pain scale
D. Urine output
Verified Answer: A
Rationale: Monitor for bleeding & neuro decline; control BP ≤ 185/110 to ↓ hemorrhage
risk.
Q5
Seizure types – tonic-clonic is classified:
A. Generalized onset
B. Focal onset
C. Unknown onset
D. Absence
Verified Answer: A
Rationale: Bilateral cerebral hemisphere involvement from onset = generalized (ILAE
2026).
Q 6 (SATA)
During active tonic-clonic seizure, nurse actions: (Select all)
REVIEW - Fortis College 2026/2027 | Neurological,
GI/Hepatobiliary, Endocrine | Grade-A Focus
SYSTEM 1 – NEUROLOGICAL NURSING (Q 1-15)
Q1
55-y/o, ischemic stroke 4 h ago; sudden slurred speech, R-sided weakness. Most
immediate action?
A. Repeat neuro check
B. Notify provider immediately
C. Reassure patient
D. Give aspirin
Verified Answer: B
Rationale: Sudden neuro change = emergency (possible hemorrhage, extension);
provider must be notified STAT for CT/CTA, possible tPA/bleed management.
Reassessment (A) follows notification.
Q 2 (SATA)
Patient at risk for ↑ ICP. Which interventions included? (Select all)
A. Head of bed 30-45°
,B. Minimize suctioning
C. Administer stool softeners
D. Space activities
E. Encourage vigorous cough
Verified Answers: A, B, C, D
Rationale: Elevate HOB 30-45° (↓ venous pressure), avoid suction stimulus, prevent
Valsalva (stool softeners), space care (↓ CO₂ spikes). Vigorous cough (E) ↑ ICP –
incorrect.
Q3
Acute ischemic stroke; last known normal 2 h ago. tPA inclusion criterion:
A. SBP 180 mmHg on 2 readings
B. INR 1.5
C. CT shows no hemorrhage
D. Platelet 80 k
Verified Answer: C
Rationale: Door-to-needle ≤ 4.5 h, non-contrast CT must rule out bleed (AHA 2026). SBP
must be ≤ 185/110, INR ≤ 1.7, platelets ≥ 100 k.
Q4
Post-tPA infusion; which assessment q 15 min × 2 h?
, A. Neuro exam & BP
B. Temperature only
C. Pain scale
D. Urine output
Verified Answer: A
Rationale: Monitor for bleeding & neuro decline; control BP ≤ 185/110 to ↓ hemorrhage
risk.
Q5
Seizure types – tonic-clonic is classified:
A. Generalized onset
B. Focal onset
C. Unknown onset
D. Absence
Verified Answer: A
Rationale: Bilateral cerebral hemisphere involvement from onset = generalized (ILAE
2026).
Q 6 (SATA)
During active tonic-clonic seizure, nurse actions: (Select all)
