NUR 242 MED SURG EXAM 4/ LATEST UPDATE
2026/ QUESTIONS WITH VERIFIED ANSWERS/A+
GRADED
Normal BP - ANSWER✔️Systolic <120 / Diastolic <80
Pre-HTN - ANSWER✔️Systolic =120-139 / Diastolic=80-89
Stage 1 HTN - ANSWER✔️Systolic=140-159 / Diastolic=90-99
Stage 2 HTN - ANSWER✔️Systolic=>160 / Diastolic=>100
Malignant HTN - ANSWER✔️Extremely high BP >180/110
,S/S of Malignant HTN - ANSWER✔️initially asymptomatic, headache upon awakening, blurred
vision, dizziness, chest pain, difficult breathing, numbness in face and legs, tinnitus, flushed face,
epistaxis
HTN Crisis - ANSWER✔️acute and life threatening; accelerated HTN requires ER treatment
because organ damage can occur quickly
Pharmacological interventions for HTN - ANSWER✔️ACE Inhibitors, Diuretics, Calcium
Channel Blockers, ARBs, and Beta Blockers
What symptom should you report right away with ACE Inhibitors? - ANSWER✔️Dry nagging
cough- discontinue immediately and teach about orthostatic HTN in elderly
What is an example of an ACE inhibitor drug? - ANSWER✔️Lisinopril, Enalapril
A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke) is
right-handed. Which task will be most difficult for this client? - ANSWER✔️Dressing every
morning
The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual
right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility
restrictions or neuromuscular abnormalities when assessing this client? - ANSWER✔️Shortening
and eventual atrophy of the affected muscles will occur
Which condition of a client with hemorrhagic stroke resulting from a motor bike accident
requires immediate attention? - ANSWER✔️Body temperature of 81.2°F
In which order would the nurse caring for a client suffering from heatstroke provide emergency
interventions? - ANSWER✔️Ensure a patent airway.
Remove the client from the hot environment.
Remove the client's clothing
Pour or spray cold water on the client's body and scalp.
Fan the client with newspapers or whatever is available.
Place ice in cloth or bags and position the packs on the client's scalp
Emergency care should be provided to the client with heatstroke to restore thermoregulation.
First the nurse would ensure a patent airway. Then the nurse would remove the client from the
hot environment into air conditioning or shade and remove his or her clothing. Then the nurse
would pour or spray cold water on the client's body and scalp. The client should be fanned with
newspapers or whatever is available. This should be followed by placing ice in cloth or bags and
positioning the packs on the client's scalp.
Which priority interventions would the nurse provide to the client hospitalized with heatstroke, a
body temperature of 106°F, and skin that is hot and dry? Select all that apply. One, some, or all
responses may be correct - ANSWER✔️Remove the client's clothing.
Immerse the client in cold water
,Which nursing intervention is the priority for a client with stroke who is transitioned from the
emergency department (ED) to other settings? - ANSWER✔️Assessing the level of consciousnes
Which client condition requires a medium priority of care according to the National Institutes of
Health Stroke Scale (NIHSS) score? - ANSWER✔️Facial palsy score of 1
The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1
year ago. Which assessment is most important for the nurse to perform before beginning the
irrigation? - ANSWER✔️pain
The body temperature of a client with heatstroke is above 104°F (40°C). Which is the priority
order the nurse would use for cooling the client so that breathing and circulation are not
impaired? - ANSWER✔️The nurse will take off the client's clothing.
The nurse would place ice packs on the neck, axillae, chest, and groin.
The nurse would immerse the victim in cold water.
The nurse would fan the client rapidly to aid in cooling by evaporation.
Which prehospital care intervention is the priority for the client with heatstroke? -
ANSWER✔️Withholding food or liquid to the victim
The client with which National Institutes of Health Stroke Scale (NIHSS) score would be treated
first? - ANSWER✔️3 for facial palsy
109 F - ANSWER✔️42.8 C (109-32):5/9
A client reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse
confirms the diagnosis as a heat stroke? - ANSWER✔️increased heart rate
An older adult client is admitted to the health care facility following a stroke. Which action is
correct when the client's cousin asks to see the client's health record? - ANSWER✔️Explain that
medical health records are confidential
The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment
the nurse determined the cardiac output as 5950. Which would be the approximate stroke
volume? - ANSWER✔️70 ml
The nurse is preparing to discharge a client who is partially paralyzed after a stroke. Which
behaviors would the nurse alert the family of as symptoms of caregiver role strain? Select all that
apply. One, some, or all responses may be correct. - ANSWER✔️Disturbed sleep patterns
Reduced appetite and weight
Fearful about administering medications to the client
Which assessment finding indicates that a client has had a stroke? Select all that apply. One,
some, or all responses may be correct. - ANSWER✔️Lopsided smile
, Unilateral vision
Incoherent speech
Unable to raise right arm
Symptoms started 2 hours ago
Which action would the nurse include in the plan of care for a client who had an ischemic stroke
caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further
strokes from occurring? Select all that apply. One, some, or all responses may be correct. -
ANSWER✔️Wearing a medical alert bracelet
Initiating bleeding precautions
Refraining from estrogen therapy
Obtaining routine prothrombin times
Notifying providers of anticoagulation
Which information would the nurse include when explaining the cause of transient ischemic
attacks (TIAs) to a client? - ANSWER✔️Atherosclerotic plaques within arteries
Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? -
ANSWER✔️Temporary episodes of neurological dysfunction
A client diagnosed with a transient ischemic attack (TIA) related to hypertension is discharged
with a prescription of hydrochlorothiazide. Which instruction would the nurse include when
teaching about this medication? - ANSWER✔️Increase the intake of potassium-rich foods."
After a short hospitalization for an episode of a transient ischemic attack (TIA) related to
hypertension, a client is discharged on a regimen that includes chlorothiazide. Which instruction
will the nurse give the client regarding nutrition? - ANSWER✔️Eat more dark green, leafy
vegetables such as spinach.
Which device would the nurse use to prevent footdrop for a client on bed rest after a
cerebrovascular accident? - ANSWER✔️Splints
The spouse of a client who had a cerebrovascular accident asks the home health nurse why the
client cries easily and without provocation. Which response would the nurse provide? -
ANSWER✔️This behavior is a common response over which the client has little control
Which goal is a priority for a client who is unconscious after a cerebrovascular accident? -
ANSWER✔️Maintaining the airway
Which is the priority nursing intervention for a client admitted to the hospital with a brain attack
(cerebrovascular accident)? - ANSWER✔️Monitoring for increased intracranial pressure
Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the
client cries easily and without provocation. Which explanation would the nurse provide about the
client's behavior? - ANSWER✔️Has little control over this behavior
2026/ QUESTIONS WITH VERIFIED ANSWERS/A+
GRADED
Normal BP - ANSWER✔️Systolic <120 / Diastolic <80
Pre-HTN - ANSWER✔️Systolic =120-139 / Diastolic=80-89
Stage 1 HTN - ANSWER✔️Systolic=140-159 / Diastolic=90-99
Stage 2 HTN - ANSWER✔️Systolic=>160 / Diastolic=>100
Malignant HTN - ANSWER✔️Extremely high BP >180/110
,S/S of Malignant HTN - ANSWER✔️initially asymptomatic, headache upon awakening, blurred
vision, dizziness, chest pain, difficult breathing, numbness in face and legs, tinnitus, flushed face,
epistaxis
HTN Crisis - ANSWER✔️acute and life threatening; accelerated HTN requires ER treatment
because organ damage can occur quickly
Pharmacological interventions for HTN - ANSWER✔️ACE Inhibitors, Diuretics, Calcium
Channel Blockers, ARBs, and Beta Blockers
What symptom should you report right away with ACE Inhibitors? - ANSWER✔️Dry nagging
cough- discontinue immediately and teach about orthostatic HTN in elderly
What is an example of an ACE inhibitor drug? - ANSWER✔️Lisinopril, Enalapril
A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke) is
right-handed. Which task will be most difficult for this client? - ANSWER✔️Dressing every
morning
The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual
right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility
restrictions or neuromuscular abnormalities when assessing this client? - ANSWER✔️Shortening
and eventual atrophy of the affected muscles will occur
Which condition of a client with hemorrhagic stroke resulting from a motor bike accident
requires immediate attention? - ANSWER✔️Body temperature of 81.2°F
In which order would the nurse caring for a client suffering from heatstroke provide emergency
interventions? - ANSWER✔️Ensure a patent airway.
Remove the client from the hot environment.
Remove the client's clothing
Pour or spray cold water on the client's body and scalp.
Fan the client with newspapers or whatever is available.
Place ice in cloth or bags and position the packs on the client's scalp
Emergency care should be provided to the client with heatstroke to restore thermoregulation.
First the nurse would ensure a patent airway. Then the nurse would remove the client from the
hot environment into air conditioning or shade and remove his or her clothing. Then the nurse
would pour or spray cold water on the client's body and scalp. The client should be fanned with
newspapers or whatever is available. This should be followed by placing ice in cloth or bags and
positioning the packs on the client's scalp.
Which priority interventions would the nurse provide to the client hospitalized with heatstroke, a
body temperature of 106°F, and skin that is hot and dry? Select all that apply. One, some, or all
responses may be correct - ANSWER✔️Remove the client's clothing.
Immerse the client in cold water
,Which nursing intervention is the priority for a client with stroke who is transitioned from the
emergency department (ED) to other settings? - ANSWER✔️Assessing the level of consciousnes
Which client condition requires a medium priority of care according to the National Institutes of
Health Stroke Scale (NIHSS) score? - ANSWER✔️Facial palsy score of 1
The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1
year ago. Which assessment is most important for the nurse to perform before beginning the
irrigation? - ANSWER✔️pain
The body temperature of a client with heatstroke is above 104°F (40°C). Which is the priority
order the nurse would use for cooling the client so that breathing and circulation are not
impaired? - ANSWER✔️The nurse will take off the client's clothing.
The nurse would place ice packs on the neck, axillae, chest, and groin.
The nurse would immerse the victim in cold water.
The nurse would fan the client rapidly to aid in cooling by evaporation.
Which prehospital care intervention is the priority for the client with heatstroke? -
ANSWER✔️Withholding food or liquid to the victim
The client with which National Institutes of Health Stroke Scale (NIHSS) score would be treated
first? - ANSWER✔️3 for facial palsy
109 F - ANSWER✔️42.8 C (109-32):5/9
A client reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse
confirms the diagnosis as a heat stroke? - ANSWER✔️increased heart rate
An older adult client is admitted to the health care facility following a stroke. Which action is
correct when the client's cousin asks to see the client's health record? - ANSWER✔️Explain that
medical health records are confidential
The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment
the nurse determined the cardiac output as 5950. Which would be the approximate stroke
volume? - ANSWER✔️70 ml
The nurse is preparing to discharge a client who is partially paralyzed after a stroke. Which
behaviors would the nurse alert the family of as symptoms of caregiver role strain? Select all that
apply. One, some, or all responses may be correct. - ANSWER✔️Disturbed sleep patterns
Reduced appetite and weight
Fearful about administering medications to the client
Which assessment finding indicates that a client has had a stroke? Select all that apply. One,
some, or all responses may be correct. - ANSWER✔️Lopsided smile
, Unilateral vision
Incoherent speech
Unable to raise right arm
Symptoms started 2 hours ago
Which action would the nurse include in the plan of care for a client who had an ischemic stroke
caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further
strokes from occurring? Select all that apply. One, some, or all responses may be correct. -
ANSWER✔️Wearing a medical alert bracelet
Initiating bleeding precautions
Refraining from estrogen therapy
Obtaining routine prothrombin times
Notifying providers of anticoagulation
Which information would the nurse include when explaining the cause of transient ischemic
attacks (TIAs) to a client? - ANSWER✔️Atherosclerotic plaques within arteries
Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? -
ANSWER✔️Temporary episodes of neurological dysfunction
A client diagnosed with a transient ischemic attack (TIA) related to hypertension is discharged
with a prescription of hydrochlorothiazide. Which instruction would the nurse include when
teaching about this medication? - ANSWER✔️Increase the intake of potassium-rich foods."
After a short hospitalization for an episode of a transient ischemic attack (TIA) related to
hypertension, a client is discharged on a regimen that includes chlorothiazide. Which instruction
will the nurse give the client regarding nutrition? - ANSWER✔️Eat more dark green, leafy
vegetables such as spinach.
Which device would the nurse use to prevent footdrop for a client on bed rest after a
cerebrovascular accident? - ANSWER✔️Splints
The spouse of a client who had a cerebrovascular accident asks the home health nurse why the
client cries easily and without provocation. Which response would the nurse provide? -
ANSWER✔️This behavior is a common response over which the client has little control
Which goal is a priority for a client who is unconscious after a cerebrovascular accident? -
ANSWER✔️Maintaining the airway
Which is the priority nursing intervention for a client admitted to the hospital with a brain attack
(cerebrovascular accident)? - ANSWER✔️Monitoring for increased intracranial pressure
Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the
client cries easily and without provocation. Which explanation would the nurse provide about the
client's behavior? - ANSWER✔️Has little control over this behavior
