Exam 4: NUR 201 Medical-Surgical Nursing I
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Integrated Content Focus: Neurological System, Gastrointestinal System &
Nutritional Support Frameworks
Q1: A 34-year-old patient with epilepsy suddenly falls to the floor and begins having generalized
tonic-clonic movements. The charge nurse rushes into the room. Which action should the nurse
take first?
A. Insert a padded tongue blade between the patient's teeth
B. Note the time and turn the patient onto their side
C. Restrain the patient's arms to prevent flailing
D. Draw up IV diazepam for immediate administration
Correct Answer: B
Rationale: Correct because the priority during an active tonic-clonic seizure is to note the exact
start time and turn the patient onto their side (recovery position) to prevent aspiration of saliva
and oral secretions, maintain airway patency, and facilitate drainage. Forcing objects into the
mouth including tongue blades, fingers, or bite blocks is absolutely contraindicated as it can
cause dental fractures, broken tooth aspiration, or airway obstruction. Restraining limbs during a
seizure can cause musculoskeletal injury including dislocations and fractures. The nurse must
never leave the bedside, should clear the immediate environment of hazards, and provide post-
ictal care including reorientation and injury assessment.
,Q2: A patient with a severe head injury from a motorcycle accident has a Glasgow Coma Scale
score of 8. The provider orders a lumbar puncture to assess for meningitis. Which nursing action
is most appropriate?
A. Prepare the lumbar puncture tray and position the patient
B. Question the order and notify the provider of the contraindication
C. Administer sedation to facilitate the procedure
D. Place the patient in Trendelenburg position for the procedure
Correct Answer: D
Rationale: Correct because lumbar puncture is strictly contraindicated in patients with decreased
level of consciousness and suspected increased intracranial pressure from head trauma, as
removing cerebrospinal fluid from the spinal column creates a rapid pressure gradient that can
pull brain tissue downward through the foramen magnum, causing fatal brain herniation. The
nurse must question the order, notify the provider of the contraindication, and advocate for
alternative diagnostic methods such as CT imaging of the head. Signs of increased ICP include
headache, vomiting, altered mental status, pupillary changes, and Cushing's triad. The nurse
should never proceed with a contraindicated procedure even if ordered.
Q3: A patient with a T6 spinal cord injury is sitting in a wheelchair and suddenly develops a
severe pounding headache. The nurse notes profuse sweating above the nipple line and a blood
pressure of 240/130 mmHg. Which condition is occurring?
A. Autonomic dysreflexia
B. Neurogenic shock
C. Spinal shock
D. Orthostatic hypotension
Correct Answer: A
Rationale: Correct because autonomic dysreflexia is a life-threatening hypertensive emergency
in patients with spinal cord injuries at or above T6, characterized by severe hypertension (often
>200/100 mmHg), throbbing headache, bradycardia, intense sweating and flushing above the
level of injury, and pale cold skin below the level of injury due to massive sympathetic discharge
from a noxious stimulus below the injury level. The priority interventions are to sit the patient
upright immediately to lower blood pressure through gravity, identify and eliminate the trigger
(most commonly a distended bladder from a blocked catheter or kinked tubing), and notify the
provider for antihypertensive orders if blood pressure remains critically elevated. If untreated,
autonomic dysreflexia can cause stroke, retinal hemorrhage, myocardial infarction, seizure, and
death.
, Q4: A patient with a right hemisphere stroke has left homonymous hemianopsia. The nurse is
preparing the patient's meal tray. Which action is most appropriate?
A. Place the call light and utensils on the left side of the tray
B. Place all items on the right side where the patient can see them
C. Position the tray so the left side faces the window
D. Ask the patient to close the left eye while eating
Correct Answer: C
Rationale: Correct because patients with left homonymous hemianopsia have lost the left visual
field in both eyes and cannot see items placed on the left side, so the nurse must place essential
items including the call light, utensils, cup, and food on the patient's unaffected (right) side to
ensure the patient can locate and use them independently. Placing items on the affected side is
ineffective as the patient will not detect them; positioning the tray to face the window does not
address the visual deficit; and asking the patient to close one eye worsens vision. The nurse
should also teach the patient to consciously scan to the left and turn the head to compensate for
the blind visual field.
Q5: A patient with acute pancreatitis reports severe, constant epigastric pain that bores straight
through to the back. The nurse observes a bluish discoloration around the patient's umbilicus.
Which sign is present?
A. Turner's sign
B. Cullen's sign
C. Grey Turner's sign
D. Kehr's sign
Correct Answer: D
Rationale: Correct because Cullen's sign is bluish discoloration around the umbilicus indicating
intraperitoneal hemorrhage, which is a hallmark of severe hemorrhagic pancreatitis caused by
retroperitoneal bleeding tracking through tissue planes to the subcutaneous periumbilical area.
Turner's sign (also called Grey Turner's sign) is bluish discoloration of the flanks indicating
retroperitoneal hemorrhage; Kehr's sign is left shoulder pain indicating splenic injury or
hemoperitoneum. The priority interventions for acute pancreatitis include strict NPO status to
rest the pancreas, NG tube decompression, aggressive IV fluid hydration, and IV pain
management with hydromorphone or morphine.
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Integrated Content Focus: Neurological System, Gastrointestinal System &
Nutritional Support Frameworks
Q1: A 34-year-old patient with epilepsy suddenly falls to the floor and begins having generalized
tonic-clonic movements. The charge nurse rushes into the room. Which action should the nurse
take first?
A. Insert a padded tongue blade between the patient's teeth
B. Note the time and turn the patient onto their side
C. Restrain the patient's arms to prevent flailing
D. Draw up IV diazepam for immediate administration
Correct Answer: B
Rationale: Correct because the priority during an active tonic-clonic seizure is to note the exact
start time and turn the patient onto their side (recovery position) to prevent aspiration of saliva
and oral secretions, maintain airway patency, and facilitate drainage. Forcing objects into the
mouth including tongue blades, fingers, or bite blocks is absolutely contraindicated as it can
cause dental fractures, broken tooth aspiration, or airway obstruction. Restraining limbs during a
seizure can cause musculoskeletal injury including dislocations and fractures. The nurse must
never leave the bedside, should clear the immediate environment of hazards, and provide post-
ictal care including reorientation and injury assessment.
,Q2: A patient with a severe head injury from a motorcycle accident has a Glasgow Coma Scale
score of 8. The provider orders a lumbar puncture to assess for meningitis. Which nursing action
is most appropriate?
A. Prepare the lumbar puncture tray and position the patient
B. Question the order and notify the provider of the contraindication
C. Administer sedation to facilitate the procedure
D. Place the patient in Trendelenburg position for the procedure
Correct Answer: D
Rationale: Correct because lumbar puncture is strictly contraindicated in patients with decreased
level of consciousness and suspected increased intracranial pressure from head trauma, as
removing cerebrospinal fluid from the spinal column creates a rapid pressure gradient that can
pull brain tissue downward through the foramen magnum, causing fatal brain herniation. The
nurse must question the order, notify the provider of the contraindication, and advocate for
alternative diagnostic methods such as CT imaging of the head. Signs of increased ICP include
headache, vomiting, altered mental status, pupillary changes, and Cushing's triad. The nurse
should never proceed with a contraindicated procedure even if ordered.
Q3: A patient with a T6 spinal cord injury is sitting in a wheelchair and suddenly develops a
severe pounding headache. The nurse notes profuse sweating above the nipple line and a blood
pressure of 240/130 mmHg. Which condition is occurring?
A. Autonomic dysreflexia
B. Neurogenic shock
C. Spinal shock
D. Orthostatic hypotension
Correct Answer: A
Rationale: Correct because autonomic dysreflexia is a life-threatening hypertensive emergency
in patients with spinal cord injuries at or above T6, characterized by severe hypertension (often
>200/100 mmHg), throbbing headache, bradycardia, intense sweating and flushing above the
level of injury, and pale cold skin below the level of injury due to massive sympathetic discharge
from a noxious stimulus below the injury level. The priority interventions are to sit the patient
upright immediately to lower blood pressure through gravity, identify and eliminate the trigger
(most commonly a distended bladder from a blocked catheter or kinked tubing), and notify the
provider for antihypertensive orders if blood pressure remains critically elevated. If untreated,
autonomic dysreflexia can cause stroke, retinal hemorrhage, myocardial infarction, seizure, and
death.
, Q4: A patient with a right hemisphere stroke has left homonymous hemianopsia. The nurse is
preparing the patient's meal tray. Which action is most appropriate?
A. Place the call light and utensils on the left side of the tray
B. Place all items on the right side where the patient can see them
C. Position the tray so the left side faces the window
D. Ask the patient to close the left eye while eating
Correct Answer: C
Rationale: Correct because patients with left homonymous hemianopsia have lost the left visual
field in both eyes and cannot see items placed on the left side, so the nurse must place essential
items including the call light, utensils, cup, and food on the patient's unaffected (right) side to
ensure the patient can locate and use them independently. Placing items on the affected side is
ineffective as the patient will not detect them; positioning the tray to face the window does not
address the visual deficit; and asking the patient to close one eye worsens vision. The nurse
should also teach the patient to consciously scan to the left and turn the head to compensate for
the blind visual field.
Q5: A patient with acute pancreatitis reports severe, constant epigastric pain that bores straight
through to the back. The nurse observes a bluish discoloration around the patient's umbilicus.
Which sign is present?
A. Turner's sign
B. Cullen's sign
C. Grey Turner's sign
D. Kehr's sign
Correct Answer: D
Rationale: Correct because Cullen's sign is bluish discoloration around the umbilicus indicating
intraperitoneal hemorrhage, which is a hallmark of severe hemorrhagic pancreatitis caused by
retroperitoneal bleeding tracking through tissue planes to the subcutaneous periumbilical area.
Turner's sign (also called Grey Turner's sign) is bluish discoloration of the flanks indicating
retroperitoneal hemorrhage; Kehr's sign is left shoulder pain indicating splenic injury or
hemoperitoneum. The priority interventions for acute pancreatitis include strict NPO status to
rest the pancreas, NG tube decompression, aggressive IV fluid hydration, and IV pain
management with hydromorphone or morphine.
