,NUR 170 Exam 2 – Med-Surg Nursing Concepts
– Actual Q&A (GCN) (Updated PDF)
1. A patient arrives at the emergency department with sudden right-sided
weakness and slurred speech that began 2 hours ago. The nurse anticipates
immediate preparation for:
A) Administration of clopidogrel
B) Tissue plasminogen activator (tPA) after confirming no contraindications
C) Carotid endarterectomy
D) High-dose corticosteroid therapy
Correct Answer: B) Tissue plasminogen activator (tPA) after confirming no
contraindications
Rationale: tPA must be given within 3-4.5 hours of ischemic stroke symptom
onset to dissolve the clot and restore perfusion. A CT scan is first obtained to
rule out hemorrhage. Antiplatelets and surgery are not acute reperfusion
therapies.
2. The nurse is assessing a client who experienced a stroke. The client speaks
fluently but uses nonsensical words and cannot follow simple commands. This is
characteristic of:
A) Expressive aphasia
B) Global aphasia
C) Receptive aphasia
D) Dysarthria
,Correct Answer: C) Receptive aphasia
Rationale: Receptive (Wernicke's) aphasia involves impaired comprehension
with fluent but meaningless speech. Expressive aphasia involves difficulty
producing speech. Global aphasia affects both. Dysarthria is a motor speech
disorder.
3. A client with a traumatic brain injury exhibits rigid extension of the arms,
pronated forearms, and plantar flexion of the feet. The nurse documents this
posture as:
A) Decorticate posturing
B) Decerebrate posturing
C) Opisthotonos
D) Flaccid paralysis
Correct Answer: B) Decerebrate posturing
Rationale: Decerebrate posturing indicates brainstem involvement and carries a
poorer prognosis. Decorticate posturing involves arm flexion toward the core.
Opisthotonos is severe hyperextension of the head and back.
4. The nurse is caring for a client with increased intracranial pressure. Which
vital sign change is consistent with Cushing's triad?
A) Hypotension, tachycardia, and tachypnea
B) Hypertension, bradycardia, and irregular respirations
C) Hypertension, tachycardia, and fever
D) Hypotension, bradycardia, and hypothermia
, Correct Answer: B) Hypertension, bradycardia, and irregular respirations
Rationale: Cushing's triad is a late sign of elevated ICP: widening pulse pressure
(hypertension), reflex bradycardia, and abnormal breathing. It indicates
brainstem compression and requires immediate notification.
5. A client with multiple sclerosis reports that her symptoms worsen when she
takes a hot shower. The nurse explains this as:
A) Uhthoff's phenomenon
B) Raynaud's phenomenon
C) Lhermitte's sign
D) Charcot's triad
Correct Answer: A) Uhthoff's phenomenon
Rationale: Uhthoff's phenomenon is the temporary worsening of neurological
symptoms with increased body temperature, common in MS. Heat slows nerve
conduction in demyelinated fibers. Lhermitte's sign is an electric shock
sensation with neck flexion.
6. The nurse is teaching a client with multiple sclerosis who is prescribed
natalizumab. Which instruction is most important?
A) Take the medication with food to decrease GI upset
B) Avoid crowds and report any signs of infection promptly
C) Monitor blood pressure daily
– Actual Q&A (GCN) (Updated PDF)
1. A patient arrives at the emergency department with sudden right-sided
weakness and slurred speech that began 2 hours ago. The nurse anticipates
immediate preparation for:
A) Administration of clopidogrel
B) Tissue plasminogen activator (tPA) after confirming no contraindications
C) Carotid endarterectomy
D) High-dose corticosteroid therapy
Correct Answer: B) Tissue plasminogen activator (tPA) after confirming no
contraindications
Rationale: tPA must be given within 3-4.5 hours of ischemic stroke symptom
onset to dissolve the clot and restore perfusion. A CT scan is first obtained to
rule out hemorrhage. Antiplatelets and surgery are not acute reperfusion
therapies.
2. The nurse is assessing a client who experienced a stroke. The client speaks
fluently but uses nonsensical words and cannot follow simple commands. This is
characteristic of:
A) Expressive aphasia
B) Global aphasia
C) Receptive aphasia
D) Dysarthria
,Correct Answer: C) Receptive aphasia
Rationale: Receptive (Wernicke's) aphasia involves impaired comprehension
with fluent but meaningless speech. Expressive aphasia involves difficulty
producing speech. Global aphasia affects both. Dysarthria is a motor speech
disorder.
3. A client with a traumatic brain injury exhibits rigid extension of the arms,
pronated forearms, and plantar flexion of the feet. The nurse documents this
posture as:
A) Decorticate posturing
B) Decerebrate posturing
C) Opisthotonos
D) Flaccid paralysis
Correct Answer: B) Decerebrate posturing
Rationale: Decerebrate posturing indicates brainstem involvement and carries a
poorer prognosis. Decorticate posturing involves arm flexion toward the core.
Opisthotonos is severe hyperextension of the head and back.
4. The nurse is caring for a client with increased intracranial pressure. Which
vital sign change is consistent with Cushing's triad?
A) Hypotension, tachycardia, and tachypnea
B) Hypertension, bradycardia, and irregular respirations
C) Hypertension, tachycardia, and fever
D) Hypotension, bradycardia, and hypothermia
, Correct Answer: B) Hypertension, bradycardia, and irregular respirations
Rationale: Cushing's triad is a late sign of elevated ICP: widening pulse pressure
(hypertension), reflex bradycardia, and abnormal breathing. It indicates
brainstem compression and requires immediate notification.
5. A client with multiple sclerosis reports that her symptoms worsen when she
takes a hot shower. The nurse explains this as:
A) Uhthoff's phenomenon
B) Raynaud's phenomenon
C) Lhermitte's sign
D) Charcot's triad
Correct Answer: A) Uhthoff's phenomenon
Rationale: Uhthoff's phenomenon is the temporary worsening of neurological
symptoms with increased body temperature, common in MS. Heat slows nerve
conduction in demyelinated fibers. Lhermitte's sign is an electric shock
sensation with neck flexion.
6. The nurse is teaching a client with multiple sclerosis who is prescribed
natalizumab. Which instruction is most important?
A) Take the medication with food to decrease GI upset
B) Avoid crowds and report any signs of infection promptly
C) Monitor blood pressure daily
