NUR 170 Exam 2 Med Surg | 120 Study Questions and
Answers + Expert Rationales | 2026 Updated | 100%
correct
1. Which of the following patients would the nurse identify as being at highest risk for stroke?
A. A 27-year-old heavy cocaine user
B. A 30-year-old who drinks one beer daily
C. A 40-year-old who uses seasonal antihistamines
D. A 65-year-old who is active and on no medications
Correct Answer: A
Expert Rationale: A 2026 meta-analysis of over 100 million participants found that cocaine use
increases stroke risk by 96%, with particularly strong associations among users under age 55 .
Cocaine causes sudden blood pressure spikes, vasospasm, and increased clotting risk. While
older age (D) is a stroke risk factor, heavy cocaine use in a young patient represents an
extremely high-risk profile. Occasional alcohol use (B) carries less risk than heavy cocaine use.
Antihistamines (C) are not significant stroke risk factors.
2. A nurse assesses a client who has a history of migraines. Which clinical manifestation
would the nurse identify as an aura?
A. Vertigo
B. Visual disturbances
C. Lethargy
D. Numbness of the tongue
Correct Answer: B
Expert Rationale: Visual disturbances—including blind spots (scotomas), zigzag lines,
shimmering spots, and flashes of light—are the most common aura symptoms, occurring in the
majority of migraine with aura cases . These visual changes typically start in the center of the
vision field and spread outward, lasting less than 60 minutes. While numbness of the tongue (D)
and vertigo (A) can occur, they are less common manifestations. Lethargy (C) is not
characteristic of migraine aura.
,3. A nurse assesses a patient with early-onset multiple sclerosis. Which clinical manifestation
would the nurse expect to find?
A. Hyperresponsive reflexes
B. Nystagmus
C. Excessive somnolence
D. Heat intolerance
Correct Answer: B
Expert Rationale: Nystagmus (involuntary eye movement) is a classic early sign of MS, reflecting
demyelination of the medial longitudinal fasciculus. Research has shown that nystagmus can
reveal latent early stages of MS . Heat intolerance (D), while common in MS, is not as specific an
early diagnostic finding as nystagmus. Hyperresponsive reflexes (A) may occur but are less
specific. Excessive somnolence (C) is not a primary early manifestation.
4. A client begins to experience a tonic-clonic seizure and loss of consciousness. What action
would the nurse take first?
A. Start fluids via a large-bore catheter
B. Administer IV push diazepam
C. Turn the client's head to the side
D. Prepare to intubate the patient
Correct Answer: C
Expert Rationale: During a tonic-clonic seizure, the priority is maintaining airway patency.
Turning the client's head to the side allows saliva and secretions to drain, preventing aspiration .
This action precedes medication administration (B), which requires IV access and a provider
order. Intubation (D) is a later consideration if airway compromise persists. IV fluids (A) are not
indicated during the active seizure.
5. A clinic nurse notes that many patients present with flu-like symptoms. Which
recommendation would the nurse NOT give to them?
A. Take antipyretics for fever
,B. Get plenty of rest
C. Increase intake of fluids
D. Get a flu shot immediately
Correct Answer: D
Expert Rationale: The flu vaccine is contraindicated during acute febrile illness. The immune
response to the vaccine may be impaired, and the patient could attribute vaccine side effects to
their illness. Rest (B), fluids (C), and antipyretics (A) are appropriate symptomatic management
for influenza.
6. When evaluating an asthma patient's knowledge, the nurse recognizes that additional
instruction is needed when the patient states:
A. "I use my corticosteroid inhaler each time I feel short of breath."
B. "I use my bronchodilator inhaler before walking so I don't become short of breath."
C. "I see my doctor if I have an upper respiratory infection and always get my flu shot."
D. "I use my bronchodilator inhaler before I visit the zoo because of my allergies."
Correct Answer: A
Expert Rationale: Corticosteroid inhalers are controller medications used daily for asthma
prevention, NOT as rescue medications for acute symptoms. They require regular use—even
when the patient feels fine—to reduce airway inflammation over time . Using a corticosteroid
inhaler only during shortness of breath demonstrates a critical misunderstanding. The
bronchodilator inhaler (B, D) is correctly used as a rescue/pre-exercise medication. Preventing
infections and getting flu shots (C) are appropriate self-management strategies.
7. A tuberculosis patient asks the nurse when it's permissible to return to work. What factor
should the nurse include when responding?
A. 5 blood cultures are negative
B. A blood culture and a chest x-ray are negative
C. 3 sputum cultures are negative
D. A sputum culture and a tuberculin skin test are negative
, Correct Answer: C
Expert Rationale: TB infectiousness is determined by sputum smear results, not blood cultures.
According to guidelines for returning to work or congregate settings, patients are considered
non-infectious when they have three consecutive negative sputum smears collected at 8-24
hour intervals (at least one early morning specimen), have been on standard TB treatment for at
least 2 weeks, and symptoms have improved . The tuberculin skin test (D) remains positive after
infection and cannot be used to determine infectiousness.
8. The emergency department nurse is monitoring an asthmatic patient during an attack. The
nurse demonstrates that respiratory status has worsened by:
A. Diminished breath sounds
B. Wheezing during exhalation
C. Wheezing during inhalation
D. Wheezing throughout the lung fields
Correct Answer: A
Expert Rationale: Diminished or absent breath sounds during an asthma attack indicate severe
airway obstruction with minimal air movement—a sign of impending respiratory failure.
Wheezing (B, C, D) indicates some degree of airflow through narrowed airways. As obstruction
worsens, the "silent chest" with diminished breath sounds is a life-threatening finding requiring
immediate intervention.
9. A patient with COPD is experiencing an exacerbation. The nurse should determine which
finding documented as an expected finding?
A. Increased O2 saturation with ambulation
B. Hyperinflation of lungs documented by chest x-ray
C. A widened diaphragm documented by chest x-ray
D. A shortened expiratory phase of the respiratory cycle
Correct Answer: B
Expert Rationale: During COPD exacerbation, dynamic hyperinflation occurs due to worsening
airflow limitation and air trapping. Chest x-ray shows hyperinflation with flattened diaphragms
Answers + Expert Rationales | 2026 Updated | 100%
correct
1. Which of the following patients would the nurse identify as being at highest risk for stroke?
A. A 27-year-old heavy cocaine user
B. A 30-year-old who drinks one beer daily
C. A 40-year-old who uses seasonal antihistamines
D. A 65-year-old who is active and on no medications
Correct Answer: A
Expert Rationale: A 2026 meta-analysis of over 100 million participants found that cocaine use
increases stroke risk by 96%, with particularly strong associations among users under age 55 .
Cocaine causes sudden blood pressure spikes, vasospasm, and increased clotting risk. While
older age (D) is a stroke risk factor, heavy cocaine use in a young patient represents an
extremely high-risk profile. Occasional alcohol use (B) carries less risk than heavy cocaine use.
Antihistamines (C) are not significant stroke risk factors.
2. A nurse assesses a client who has a history of migraines. Which clinical manifestation
would the nurse identify as an aura?
A. Vertigo
B. Visual disturbances
C. Lethargy
D. Numbness of the tongue
Correct Answer: B
Expert Rationale: Visual disturbances—including blind spots (scotomas), zigzag lines,
shimmering spots, and flashes of light—are the most common aura symptoms, occurring in the
majority of migraine with aura cases . These visual changes typically start in the center of the
vision field and spread outward, lasting less than 60 minutes. While numbness of the tongue (D)
and vertigo (A) can occur, they are less common manifestations. Lethargy (C) is not
characteristic of migraine aura.
,3. A nurse assesses a patient with early-onset multiple sclerosis. Which clinical manifestation
would the nurse expect to find?
A. Hyperresponsive reflexes
B. Nystagmus
C. Excessive somnolence
D. Heat intolerance
Correct Answer: B
Expert Rationale: Nystagmus (involuntary eye movement) is a classic early sign of MS, reflecting
demyelination of the medial longitudinal fasciculus. Research has shown that nystagmus can
reveal latent early stages of MS . Heat intolerance (D), while common in MS, is not as specific an
early diagnostic finding as nystagmus. Hyperresponsive reflexes (A) may occur but are less
specific. Excessive somnolence (C) is not a primary early manifestation.
4. A client begins to experience a tonic-clonic seizure and loss of consciousness. What action
would the nurse take first?
A. Start fluids via a large-bore catheter
B. Administer IV push diazepam
C. Turn the client's head to the side
D. Prepare to intubate the patient
Correct Answer: C
Expert Rationale: During a tonic-clonic seizure, the priority is maintaining airway patency.
Turning the client's head to the side allows saliva and secretions to drain, preventing aspiration .
This action precedes medication administration (B), which requires IV access and a provider
order. Intubation (D) is a later consideration if airway compromise persists. IV fluids (A) are not
indicated during the active seizure.
5. A clinic nurse notes that many patients present with flu-like symptoms. Which
recommendation would the nurse NOT give to them?
A. Take antipyretics for fever
,B. Get plenty of rest
C. Increase intake of fluids
D. Get a flu shot immediately
Correct Answer: D
Expert Rationale: The flu vaccine is contraindicated during acute febrile illness. The immune
response to the vaccine may be impaired, and the patient could attribute vaccine side effects to
their illness. Rest (B), fluids (C), and antipyretics (A) are appropriate symptomatic management
for influenza.
6. When evaluating an asthma patient's knowledge, the nurse recognizes that additional
instruction is needed when the patient states:
A. "I use my corticosteroid inhaler each time I feel short of breath."
B. "I use my bronchodilator inhaler before walking so I don't become short of breath."
C. "I see my doctor if I have an upper respiratory infection and always get my flu shot."
D. "I use my bronchodilator inhaler before I visit the zoo because of my allergies."
Correct Answer: A
Expert Rationale: Corticosteroid inhalers are controller medications used daily for asthma
prevention, NOT as rescue medications for acute symptoms. They require regular use—even
when the patient feels fine—to reduce airway inflammation over time . Using a corticosteroid
inhaler only during shortness of breath demonstrates a critical misunderstanding. The
bronchodilator inhaler (B, D) is correctly used as a rescue/pre-exercise medication. Preventing
infections and getting flu shots (C) are appropriate self-management strategies.
7. A tuberculosis patient asks the nurse when it's permissible to return to work. What factor
should the nurse include when responding?
A. 5 blood cultures are negative
B. A blood culture and a chest x-ray are negative
C. 3 sputum cultures are negative
D. A sputum culture and a tuberculin skin test are negative
, Correct Answer: C
Expert Rationale: TB infectiousness is determined by sputum smear results, not blood cultures.
According to guidelines for returning to work or congregate settings, patients are considered
non-infectious when they have three consecutive negative sputum smears collected at 8-24
hour intervals (at least one early morning specimen), have been on standard TB treatment for at
least 2 weeks, and symptoms have improved . The tuberculin skin test (D) remains positive after
infection and cannot be used to determine infectiousness.
8. The emergency department nurse is monitoring an asthmatic patient during an attack. The
nurse demonstrates that respiratory status has worsened by:
A. Diminished breath sounds
B. Wheezing during exhalation
C. Wheezing during inhalation
D. Wheezing throughout the lung fields
Correct Answer: A
Expert Rationale: Diminished or absent breath sounds during an asthma attack indicate severe
airway obstruction with minimal air movement—a sign of impending respiratory failure.
Wheezing (B, C, D) indicates some degree of airflow through narrowed airways. As obstruction
worsens, the "silent chest" with diminished breath sounds is a life-threatening finding requiring
immediate intervention.
9. A patient with COPD is experiencing an exacerbation. The nurse should determine which
finding documented as an expected finding?
A. Increased O2 saturation with ambulation
B. Hyperinflation of lungs documented by chest x-ray
C. A widened diaphragm documented by chest x-ray
D. A shortened expiratory phase of the respiratory cycle
Correct Answer: B
Expert Rationale: During COPD exacerbation, dynamic hyperinflation occurs due to worsening
airflow limitation and air trapping. Chest x-ray shows hyperinflation with flattened diaphragms
