NUR 242 EXAM 4
Medical-Surgical Nursing Concepts
Galen College of Nursing
High-Yield Qs to mirror the Exam
Verified Answers with Rationales
This Exam Features:
NUR 242 Exam 4 Mental Health Nursing (Galen
College) including 50 high-yield questions
written to mirror actual course exams. Covers
core Medical-Surgical Nursing Concepts with clear,
accurate, and student-friendly explanations. Perfect for mastering
high-priority topics and boosting exam confidence.
,1.
A client with a traumatic brain injury becomes increasingly restless, has a
headache, and the nurse notes unequal pupils and a blood pressure of
180/60 mm Hg. What is the priority action?
A. Reorient the client and dim the lights
B. Administer prescribed PRN opioid analgesic
C. Elevate the head of the bed 30 degrees and notify the provider
D. Instruct the client to take slow, deep breaths
Correct Answer: C
Expert rationale: Restlessness, headache, anisocoria (unequal
pupils), and widened pulse pressure indicate rising intracranial
pressure (ICP). Elevating the head of the bed about 30° promotes
venous drainage from the brain and helps decrease ICP. The provider
must be notified immediately. Opioids can mask neurologic changes,
and other options do not address the life-threatening ICP.
2.
A client with increased intracranial pressure (ICP) is receiving mechanical
ventilation. Which ventilator setting change should the nurse question?
A. Increasing the respiratory rate to lower PaCO₂
B. Increasing positive end-expiratory pressure (PEEP)
C. Maintaining FiO₂ at 40%
D. Keeping tidal volume within normal range
Correct Answer: B
Expert rationale: High PEEP increases intrathoracic pressure, which
can reduce venous return from the brain and worsen ICP. Mild
hyperventilation (lower PaCO₂) causes cerebral vasoconstriction and
can help lower ICP short term, and normal tidal volume and FiO₂ are
not problematic.
,3.
The nurse is caring for a client with a history of generalized tonic–clonic
seizures. Which intervention has the highest priority when a seizure
begins?
A. Insert a padded tongue blade
B. Restrain the client’s arms and legs
C. Turn the client to the side and protect the head
D. Check the client’s temperature
Correct Answer: C
Expert rationale: During an active seizure, airway and safety are
priorities. Turning the client to the side helps prevent aspiration, and
protecting the head prevents trauma. Never put anything in the
client’s mouth or restrain limbs.
4.
A client with a spinal cord injury at T4 suddenly develops a severe
headache, flushed face, and a blood pressure of 220/110 mm Hg. What is
the nurse’s priority action?
A. Lower the head of the bed
B. Check the bladder and catheter for kinks
C. Apply a warming blanket
D. Administer PRN IV hydralazine
Correct Answer: B
Expert rationale: These symptoms suggest autonomic dysreflexia,
usually triggered by noxious stimuli below the level of injury—most
commonly a distended bladder. The nurse should first identify and
remove the cause (e.g., kinked catheter). Antihypertensives may be
, required but only after addressing the trigger. The HOB should be
raised, not lowered.
5.
The nurse is teaching a client 1 day post–total hip replacement (posterior
approach). Which statement indicates a need for further teaching?
A. “I will avoid crossing my legs while sitting.”
B. “I will use a pillow between my legs when I turn.”
C. “I can bend at my hip to tie my shoes as long as I move slowly.”
D. “I will use the raised toilet seat at home.”
Correct Answer: C
Expert rationale: After a posterior-approach hip replacement, the
client must avoid hip flexion greater than 90°, adduction, and internal
rotation to prevent dislocation. Bending to tie shoes violates that
precaution. The other statements reflect correct precautions.
6.
A client with a long leg cast reports severe pain unrelieved by opioids, and
the nurse notes pallor and paresthesia of the toes. What is the most
appropriate action?
A. Elevate the leg above heart level
B. Apply ice packs to the cast
C. Notify the provider immediately
D. Reassure the client this is expected
Correct Answer: C
Expert rationale: Severe pain out of proportion, paresthesia, and
pallor suggest acute compartment syndrome, a limb-threatening
emergency. The provider must be called immediately for possible
Medical-Surgical Nursing Concepts
Galen College of Nursing
High-Yield Qs to mirror the Exam
Verified Answers with Rationales
This Exam Features:
NUR 242 Exam 4 Mental Health Nursing (Galen
College) including 50 high-yield questions
written to mirror actual course exams. Covers
core Medical-Surgical Nursing Concepts with clear,
accurate, and student-friendly explanations. Perfect for mastering
high-priority topics and boosting exam confidence.
,1.
A client with a traumatic brain injury becomes increasingly restless, has a
headache, and the nurse notes unequal pupils and a blood pressure of
180/60 mm Hg. What is the priority action?
A. Reorient the client and dim the lights
B. Administer prescribed PRN opioid analgesic
C. Elevate the head of the bed 30 degrees and notify the provider
D. Instruct the client to take slow, deep breaths
Correct Answer: C
Expert rationale: Restlessness, headache, anisocoria (unequal
pupils), and widened pulse pressure indicate rising intracranial
pressure (ICP). Elevating the head of the bed about 30° promotes
venous drainage from the brain and helps decrease ICP. The provider
must be notified immediately. Opioids can mask neurologic changes,
and other options do not address the life-threatening ICP.
2.
A client with increased intracranial pressure (ICP) is receiving mechanical
ventilation. Which ventilator setting change should the nurse question?
A. Increasing the respiratory rate to lower PaCO₂
B. Increasing positive end-expiratory pressure (PEEP)
C. Maintaining FiO₂ at 40%
D. Keeping tidal volume within normal range
Correct Answer: B
Expert rationale: High PEEP increases intrathoracic pressure, which
can reduce venous return from the brain and worsen ICP. Mild
hyperventilation (lower PaCO₂) causes cerebral vasoconstriction and
can help lower ICP short term, and normal tidal volume and FiO₂ are
not problematic.
,3.
The nurse is caring for a client with a history of generalized tonic–clonic
seizures. Which intervention has the highest priority when a seizure
begins?
A. Insert a padded tongue blade
B. Restrain the client’s arms and legs
C. Turn the client to the side and protect the head
D. Check the client’s temperature
Correct Answer: C
Expert rationale: During an active seizure, airway and safety are
priorities. Turning the client to the side helps prevent aspiration, and
protecting the head prevents trauma. Never put anything in the
client’s mouth or restrain limbs.
4.
A client with a spinal cord injury at T4 suddenly develops a severe
headache, flushed face, and a blood pressure of 220/110 mm Hg. What is
the nurse’s priority action?
A. Lower the head of the bed
B. Check the bladder and catheter for kinks
C. Apply a warming blanket
D. Administer PRN IV hydralazine
Correct Answer: B
Expert rationale: These symptoms suggest autonomic dysreflexia,
usually triggered by noxious stimuli below the level of injury—most
commonly a distended bladder. The nurse should first identify and
remove the cause (e.g., kinked catheter). Antihypertensives may be
, required but only after addressing the trigger. The HOB should be
raised, not lowered.
5.
The nurse is teaching a client 1 day post–total hip replacement (posterior
approach). Which statement indicates a need for further teaching?
A. “I will avoid crossing my legs while sitting.”
B. “I will use a pillow between my legs when I turn.”
C. “I can bend at my hip to tie my shoes as long as I move slowly.”
D. “I will use the raised toilet seat at home.”
Correct Answer: C
Expert rationale: After a posterior-approach hip replacement, the
client must avoid hip flexion greater than 90°, adduction, and internal
rotation to prevent dislocation. Bending to tie shoes violates that
precaution. The other statements reflect correct precautions.
6.
A client with a long leg cast reports severe pain unrelieved by opioids, and
the nurse notes pallor and paresthesia of the toes. What is the most
appropriate action?
A. Elevate the leg above heart level
B. Apply ice packs to the cast
C. Notify the provider immediately
D. Reassure the client this is expected
Correct Answer: C
Expert rationale: Severe pain out of proportion, paresthesia, and
pallor suggest acute compartment syndrome, a limb-threatening
emergency. The provider must be called immediately for possible
