NSG 233 Med Surg 3 Exam 4
Herzing Questions and Ansẉers with
rationales 2026\2027 update
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Questions and Ansẉers
format set of multiple-choice
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1. A patient with a traumatic brain injury (TBI) is exhibiting a systolic
blood pressure of 200 mmHg, a heart rate of 45 beats/min, and an
irregular respiratory pattern. The nurse recognizes this as:
A. Hypovolemic shock
B. Cushing's triad
C. Multiple organ dysfunction syndrome
D. Neurogenic shock
Answer: B. Cushing's triad
Rationale: Cushing's triad is a classic sign of late increased
intracranial pressure (ICP) and impending brain herniation. It is
characterized by systolic hypertension with a widened pulse
pressure, bradycardia, and irregular respirations (often Cheyne-
Stokes). Immediate intervention to lower ICP is required.
2. A patient is admitted with a suspected stroke. The nurse notes
the patient is experiencing dysphagia. Which of the following
interventions should the nurse implement first?
A. Place the patient on NPO status
B. Request a speech therapy consultation
C. Administer IV fluids
D. Provide thickened liquids
Answer: A. Place the patient on NPO status
Rationale: Due to dysphagia, the patient is at high risk for
aspiration. The priority intervention is to place the patient on NPO
(nothing by mouth) status until a swallow evaluation can be
performed by a speech-language pathologist to prevent aspiration
pneumonia.
, 3. A patient is receiving intravenous alteplase (tPA) for an ischemic
stroke. The nurse observes the patient for which of the following
potential complications?
A. Hypoglycemia
B. Hemorrhage
C. Hypertension
D. Seizures
Answer: B. Hemorrhage
Rationale: Alteplase is a thrombolytic agent that dissolves clots but
significantly increases the risk for bleeding. The nurse must closely
monitor the patient for signs of intracranial hemorrhage and
systemic bleeding, such as a drop in level of consciousness,
increased ICP, or oozing from IV sites.
4. A nurse is caring for a patient with a subarachnoid hemorrhage.
The patient complains of a sudden, severe "thunderclap" headache.
What is the priority nursing action?
A. Administer acetaminophen for pain
B. Dim the lights and keep the room quiet
C. Assess for changes in level of consciousness and pupil symmetry
D. Call the provider to request a CT scan
Answer: C. Assess for changes in level of consciousness and pupil
symmetry
Rationale: A sudden, severe headache in a patient with a
subarachnoid hemorrhage may indicate rebleeding or increased ICP.
The priority is to assess for neurological deterioration (changes in
LOC, pupils, motor function) before administering medications or
calling the provider.
5. A patient with a spinal cord injury at the C7 level reports a
sudden, severe pounding headache. The nurse notes the patient’s
blood pressure is 210/120 mmHg and heart rate is 48 beats/min.
What is the priority intervention?
A. Administer a beta-blocker as ordered
Herzing Questions and Ansẉers with
rationales 2026\2027 update
This Exam contains:
Guarantee passing score
Questions and Ansẉers
format set of multiple-choice
Expert-Verified rationales
Verified ẉith trusted textbooks
,───────────────────────────────────────────────────────
─
1. A patient with a traumatic brain injury (TBI) is exhibiting a systolic
blood pressure of 200 mmHg, a heart rate of 45 beats/min, and an
irregular respiratory pattern. The nurse recognizes this as:
A. Hypovolemic shock
B. Cushing's triad
C. Multiple organ dysfunction syndrome
D. Neurogenic shock
Answer: B. Cushing's triad
Rationale: Cushing's triad is a classic sign of late increased
intracranial pressure (ICP) and impending brain herniation. It is
characterized by systolic hypertension with a widened pulse
pressure, bradycardia, and irregular respirations (often Cheyne-
Stokes). Immediate intervention to lower ICP is required.
2. A patient is admitted with a suspected stroke. The nurse notes
the patient is experiencing dysphagia. Which of the following
interventions should the nurse implement first?
A. Place the patient on NPO status
B. Request a speech therapy consultation
C. Administer IV fluids
D. Provide thickened liquids
Answer: A. Place the patient on NPO status
Rationale: Due to dysphagia, the patient is at high risk for
aspiration. The priority intervention is to place the patient on NPO
(nothing by mouth) status until a swallow evaluation can be
performed by a speech-language pathologist to prevent aspiration
pneumonia.
, 3. A patient is receiving intravenous alteplase (tPA) for an ischemic
stroke. The nurse observes the patient for which of the following
potential complications?
A. Hypoglycemia
B. Hemorrhage
C. Hypertension
D. Seizures
Answer: B. Hemorrhage
Rationale: Alteplase is a thrombolytic agent that dissolves clots but
significantly increases the risk for bleeding. The nurse must closely
monitor the patient for signs of intracranial hemorrhage and
systemic bleeding, such as a drop in level of consciousness,
increased ICP, or oozing from IV sites.
4. A nurse is caring for a patient with a subarachnoid hemorrhage.
The patient complains of a sudden, severe "thunderclap" headache.
What is the priority nursing action?
A. Administer acetaminophen for pain
B. Dim the lights and keep the room quiet
C. Assess for changes in level of consciousness and pupil symmetry
D. Call the provider to request a CT scan
Answer: C. Assess for changes in level of consciousness and pupil
symmetry
Rationale: A sudden, severe headache in a patient with a
subarachnoid hemorrhage may indicate rebleeding or increased ICP.
The priority is to assess for neurological deterioration (changes in
LOC, pupils, motor function) before administering medications or
calling the provider.
5. A patient with a spinal cord injury at the C7 level reports a
sudden, severe pounding headache. The nurse notes the patient’s
blood pressure is 210/120 mmHg and heart rate is 48 beats/min.
What is the priority intervention?
A. Administer a beta-blocker as ordered
