,26/27NUR 201/NUR201 EXAM 3 MEDICAL-SURGICAL
NURSING I |JERSY COLLEGE| Q&A & RATIONALES
1. A patient arrives in the emergency department with sudden facial droop, right-arm
weakness, and difficulty speaking that began 25 minutes ago. Which action is the
nurse's priority?
A) Give oral fluids
B) Activate the stroke response protocol
C) Place the patient in Trendelenburg position
D) Delay evaluation until symptoms persist for 24 hours
Correct Answer: Activate the stroke response protocol
Rationale: Sudden unilateral weakness, facial droop, and speech difficulty strongly suggest
an acute stroke. Stroke treatment is highly time dependent, so the exact last-known-well
time, rapid neurologic assessment, blood glucose, brain imaging, and evaluation for
reperfusion therapy must occur urgently. Oral intake should be withheld until swallowing
is evaluated because dysphagia may increase aspiration risk.
2. Which finding is most characteristic of increased intracranial pressure?
A) Bradycardia with widening pulse pressure
B) Hypotension with narrow pulse pressure
C) Persistent tachycardia with low blood pressure only
D) Polyuria and excessive thirst
Correct Answer: Bradycardia with widening pulse pressure
Rationale: Increased intracranial pressure may eventually produce Cushing response:
hypertension with widening pulse pressure, bradycardia, and abnormal respirations. These
are late and ominous signs indicating compromised cerebral perfusion and possible
herniation. Early findings may include headache, vomiting, altered level of consciousness,
restlessness, and pupillary changes.
3. A patient with a head injury becomes increasingly difficult to arouse. Which
nursing action has highest priority?
A) Reassess neurologic status immediately
B) Encourage uninterrupted sleep for 8 hours
C) Offer a high-protein meal
D) Ambulate the patient independently
Correct Answer: Reassess neurologic status immediately
Rationale: A declining level of consciousness after head injury may indicate expanding
intracranial bleeding, cerebral edema, or worsening intracranial pressure. Neurologic
deterioration must be recognized promptly. The nurse should reassess Glasgow Coma
, Scale components, pupils, motor response, vital signs, and respiratory status and obtain
urgent medical evaluation.
4. Which position is generally appropriate for a patient with increased intracranial
pressure unless contraindicated?
A) Head of bed elevated about 30 degrees with neck midline
B) Flat with extreme neck flexion
C) Trendelenburg position
D) Prone with head dependent
Correct Answer: Head of bed elevated about 30 degrees with neck midline
Rationale: Elevating the head while maintaining neutral head and neck alignment
promotes cerebral venous drainage and may help reduce intracranial pressure. Excessive
hip or neck flexion can obstruct venous return and increase intracranial pressure.
Positioning must be individualized in patients with unstable blood pressure or spinal
injury.
5. Which assessment finding is most consistent with meningitis?
A) Nuchal rigidity and photophobia
B) Painless edema of both ankles
C) Hyperactive bowel sounds only
D) Polyuria without neurologic symptoms
Correct Answer: Nuchal rigidity and photophobia
Rationale: Meningeal inflammation commonly produces severe headache, fever, neck
stiffness, photophobia, nausea, and altered mental status. Bacterial meningitis is a medical
emergency because neurologic deterioration and sepsis can occur rapidly. Isolation
precautions may be required depending on the causative organism.
6. A patient is actively having a generalized tonic-clonic seizure. What should the
nurse do?
A) Restrain the patient's extremities
B) Insert a tongue blade into the mouth
C) Protect the patient from injury and maintain airway safety
D) Force oral medication between the teeth
Correct Answer: Protect the patient from injury and maintain airway safety
Rationale: During a seizure, the nurse should protect the head, remove nearby hazards,
loosen restrictive clothing, maintain privacy, and position the patient to support airway
drainage when possible. Nothing should be forced into the mouth because this may injure
the teeth, jaw, or airway. Restraining the limbs can cause musculoskeletal injury.
NURSING I |JERSY COLLEGE| Q&A & RATIONALES
1. A patient arrives in the emergency department with sudden facial droop, right-arm
weakness, and difficulty speaking that began 25 minutes ago. Which action is the
nurse's priority?
A) Give oral fluids
B) Activate the stroke response protocol
C) Place the patient in Trendelenburg position
D) Delay evaluation until symptoms persist for 24 hours
Correct Answer: Activate the stroke response protocol
Rationale: Sudden unilateral weakness, facial droop, and speech difficulty strongly suggest
an acute stroke. Stroke treatment is highly time dependent, so the exact last-known-well
time, rapid neurologic assessment, blood glucose, brain imaging, and evaluation for
reperfusion therapy must occur urgently. Oral intake should be withheld until swallowing
is evaluated because dysphagia may increase aspiration risk.
2. Which finding is most characteristic of increased intracranial pressure?
A) Bradycardia with widening pulse pressure
B) Hypotension with narrow pulse pressure
C) Persistent tachycardia with low blood pressure only
D) Polyuria and excessive thirst
Correct Answer: Bradycardia with widening pulse pressure
Rationale: Increased intracranial pressure may eventually produce Cushing response:
hypertension with widening pulse pressure, bradycardia, and abnormal respirations. These
are late and ominous signs indicating compromised cerebral perfusion and possible
herniation. Early findings may include headache, vomiting, altered level of consciousness,
restlessness, and pupillary changes.
3. A patient with a head injury becomes increasingly difficult to arouse. Which
nursing action has highest priority?
A) Reassess neurologic status immediately
B) Encourage uninterrupted sleep for 8 hours
C) Offer a high-protein meal
D) Ambulate the patient independently
Correct Answer: Reassess neurologic status immediately
Rationale: A declining level of consciousness after head injury may indicate expanding
intracranial bleeding, cerebral edema, or worsening intracranial pressure. Neurologic
deterioration must be recognized promptly. The nurse should reassess Glasgow Coma
, Scale components, pupils, motor response, vital signs, and respiratory status and obtain
urgent medical evaluation.
4. Which position is generally appropriate for a patient with increased intracranial
pressure unless contraindicated?
A) Head of bed elevated about 30 degrees with neck midline
B) Flat with extreme neck flexion
C) Trendelenburg position
D) Prone with head dependent
Correct Answer: Head of bed elevated about 30 degrees with neck midline
Rationale: Elevating the head while maintaining neutral head and neck alignment
promotes cerebral venous drainage and may help reduce intracranial pressure. Excessive
hip or neck flexion can obstruct venous return and increase intracranial pressure.
Positioning must be individualized in patients with unstable blood pressure or spinal
injury.
5. Which assessment finding is most consistent with meningitis?
A) Nuchal rigidity and photophobia
B) Painless edema of both ankles
C) Hyperactive bowel sounds only
D) Polyuria without neurologic symptoms
Correct Answer: Nuchal rigidity and photophobia
Rationale: Meningeal inflammation commonly produces severe headache, fever, neck
stiffness, photophobia, nausea, and altered mental status. Bacterial meningitis is a medical
emergency because neurologic deterioration and sepsis can occur rapidly. Isolation
precautions may be required depending on the causative organism.
6. A patient is actively having a generalized tonic-clonic seizure. What should the
nurse do?
A) Restrain the patient's extremities
B) Insert a tongue blade into the mouth
C) Protect the patient from injury and maintain airway safety
D) Force oral medication between the teeth
Correct Answer: Protect the patient from injury and maintain airway safety
Rationale: During a seizure, the nurse should protect the head, remove nearby hazards,
loosen restrictive clothing, maintain privacy, and position the patient to support airway
drainage when possible. Nothing should be forced into the mouth because this may injure
the teeth, jaw, or airway. Restraining the limbs can cause musculoskeletal injury.
