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 28-year-old patient with a history of epilepsy begins having a tonic-clonic seizure in the
hospital room. Which action should the nurse take first?
A. Force a padded tongue blade between the patient's teeth
B. Turn the patient to the side and clear the immediate area of hazards
C. Restrain the patient's limbs to prevent injury
D. Insert an oropharyngeal airway to maintain patency
Correct Answer: B
Rationale: Correct because the priority during an active tonic-clonic seizure is to turn the patient
to the side (recovery position) to prevent aspiration of saliva and oral secretions, maintain airway
patency, and facilitate drainage, while simultaneously clearing the immediate environment of
furniture and objects that could cause injury. 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 time the seizure, and provide post-ictal care including reorientation and injury
assessment.
,Q2: A patient with acute head trauma and suspected increased intracranial pressure is scheduled
for a lumbar puncture. Which nursing action is most appropriate?
A. Assist with the procedure to obtain CSF for analysis
B. Notify the provider that lumbar puncture is contraindicated
C. Administer sedation to reduce patient anxiety
D. Position the patient in Trendelenburg for the procedure
Correct Answer: D
Rationale: Correct because lumbar puncture is strictly contraindicated in patients with acute
head trauma and suspected increased intracranial pressure, 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 immediately notify the
provider of this contraindication and advocate for alternative diagnostic methods such as CT
imaging. Signs of increased ICP include headache, vomiting, decreased level of consciousness,
pupillary changes (blown pupil from CN III compression), and Cushing's triad (hypertension,
bradycardia, irregular respirations). Management includes head of bed at 30 degrees, avoiding
Valsalva maneuvers, osmotic diuretics, and possible decompressive craniectomy.
Q3: A patient with a spinal cord injury at T4 reports a pounding headache, profuse sweating
above the level of injury, and nasal congestion. The blood pressure is 220/118 mmHg. Which
condition should the nurse suspect?
A. Neurogenic shock
B. Autonomic dysreflexia
C. Spinal shock
D. Malignant hypertension
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, 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 six hours post-stroke has left-sided homonymous hemianopsia. Which nursing
intervention is most appropriate?
A. Approach the patient from the left side to encourage visual scanning
B. Place the call light and personal items on the patient's right side
C. Patch the right eye to improve vision in the left eye
D. Position the bed so the left side faces the door
Correct Answer: C
Rationale: Correct because homonymous hemianopsia is visual field loss on the same side of
both eyes (left visual field loss in both eyes in this case), and the nurse must place essential items
including the call light, personal belongings, and bed controls on the patient's unaffected side
(right side) so the patient can see and access them. Approaching from the affected side startles
the patient who cannot see the nurse; patching the unaffected eye worsens vision; and positioning
the bed to face the affected side toward the door increases fall risk and anxiety. In the
rehabilitation phase, the nurse should teach the patient to consciously scan from side to side and
turn the head to compensate for the visual deficit.
Q5: A patient with acute pancreatitis reports severe, boring epigastric pain that radiates directly
through to the back. The nurse notes bluish discoloration around the flanks. Which sign is
present?
A. Cullen's sign
B. Turner's sign
C. Grey Turner's sign
D. McBurney's sign
Correct Answer: D
Rationale: Correct because Turner's sign is bluish discoloration of the flanks indicating
retroperitoneal hemorrhage, which is a hallmark of severe hemorrhagic pancreatitis caused by
retroperitoneal bleeding tracking through tissue planes to the subcutaneous tissues. Cullen's sign
is bluish discoloration around the umbilicus indicating intraperitoneal hemorrhage; Grey Turner's
sign is synonymous with Turner's sign; and McBurney's sign is tenderness at the right lower
quadrant indicating appendicitis. 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 28-year-old patient with a history of epilepsy begins having a tonic-clonic seizure in the
hospital room. Which action should the nurse take first?
A. Force a padded tongue blade between the patient's teeth
B. Turn the patient to the side and clear the immediate area of hazards
C. Restrain the patient's limbs to prevent injury
D. Insert an oropharyngeal airway to maintain patency
Correct Answer: B
Rationale: Correct because the priority during an active tonic-clonic seizure is to turn the patient
to the side (recovery position) to prevent aspiration of saliva and oral secretions, maintain airway
patency, and facilitate drainage, while simultaneously clearing the immediate environment of
furniture and objects that could cause injury. 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 time the seizure, and provide post-ictal care including reorientation and injury
assessment.
,Q2: A patient with acute head trauma and suspected increased intracranial pressure is scheduled
for a lumbar puncture. Which nursing action is most appropriate?
A. Assist with the procedure to obtain CSF for analysis
B. Notify the provider that lumbar puncture is contraindicated
C. Administer sedation to reduce patient anxiety
D. Position the patient in Trendelenburg for the procedure
Correct Answer: D
Rationale: Correct because lumbar puncture is strictly contraindicated in patients with acute
head trauma and suspected increased intracranial pressure, 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 immediately notify the
provider of this contraindication and advocate for alternative diagnostic methods such as CT
imaging. Signs of increased ICP include headache, vomiting, decreased level of consciousness,
pupillary changes (blown pupil from CN III compression), and Cushing's triad (hypertension,
bradycardia, irregular respirations). Management includes head of bed at 30 degrees, avoiding
Valsalva maneuvers, osmotic diuretics, and possible decompressive craniectomy.
Q3: A patient with a spinal cord injury at T4 reports a pounding headache, profuse sweating
above the level of injury, and nasal congestion. The blood pressure is 220/118 mmHg. Which
condition should the nurse suspect?
A. Neurogenic shock
B. Autonomic dysreflexia
C. Spinal shock
D. Malignant hypertension
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, 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 six hours post-stroke has left-sided homonymous hemianopsia. Which nursing
intervention is most appropriate?
A. Approach the patient from the left side to encourage visual scanning
B. Place the call light and personal items on the patient's right side
C. Patch the right eye to improve vision in the left eye
D. Position the bed so the left side faces the door
Correct Answer: C
Rationale: Correct because homonymous hemianopsia is visual field loss on the same side of
both eyes (left visual field loss in both eyes in this case), and the nurse must place essential items
including the call light, personal belongings, and bed controls on the patient's unaffected side
(right side) so the patient can see and access them. Approaching from the affected side startles
the patient who cannot see the nurse; patching the unaffected eye worsens vision; and positioning
the bed to face the affected side toward the door increases fall risk and anxiety. In the
rehabilitation phase, the nurse should teach the patient to consciously scan from side to side and
turn the head to compensate for the visual deficit.
Q5: A patient with acute pancreatitis reports severe, boring epigastric pain that radiates directly
through to the back. The nurse notes bluish discoloration around the flanks. Which sign is
present?
A. Cullen's sign
B. Turner's sign
C. Grey Turner's sign
D. McBurney's sign
Correct Answer: D
Rationale: Correct because Turner's sign is bluish discoloration of the flanks indicating
retroperitoneal hemorrhage, which is a hallmark of severe hemorrhagic pancreatitis caused by
retroperitoneal bleeding tracking through tissue planes to the subcutaneous tissues. Cullen's sign
is bluish discoloration around the umbilicus indicating intraperitoneal hemorrhage; Grey Turner's
sign is synonymous with Turner's sign; and McBurney's sign is tenderness at the right lower
quadrant indicating appendicitis. 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.
