NSG 233 Med Surg 3 Exam 2
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1. A nurse is assessing a client who has a closed head injury. The
client displays decorticate posturing. Which of the following
describes this posture?
A. Extension of both upper and lower extremities
B. Flexion of the upper extremities and extension of the lower
extremities
C. Extension of the upper extremities and flexion of the lower
extremities
D. Flaccid paralysis of all extremities
Answer: B. Flexion of the upper extremities and extension of the
lower extremities
Rationale: Decorticate posturing (abnormal flexion) indicates
damage to the cerebral hemispheres or internal capsule. The arms
are flexed tightly to the core, and the legs are extended.
Decerebrate posturing (Option A) indicates damage to the brainstem
and involves extension of both upper and lower extremities.
2. A client is admitted with a suspected cerebrovascular accident
(CVA). The nurse knows that the window of opportunity for
administering alteplase (tPA) is within how many hours of symptom
onset?
A. 1.5 hours
B. 3 hours
C. 6 hours
D. 12 hours
Answer: B. 3 hours
Rationale: Alteplase is a thrombolytic agent used to dissolve the clot
in an ischemic stroke. It must be administered within 3 to 4.5 hours
of the onset of symptoms to be effective and reduce the risk of
hemorrhagic transformation.
, 3. A client who suffered a spinal cord injury at the T6 level
complains of a severe, pounding headache. The nurse notes the
client is diaphoretic and has a blood pressure of 210/120 mm Hg.
Which of the following actions should the nurse take first?
A. Administer acetaminophen
B. Check the bladder for distention
C. Elevate the head of the bed
D. Prepare to administer IV nitroprusside
Answer: C. Elevate the head of the bed
Rationale: This client is experiencing autonomic dysreflexia, a life-
threatening emergency. The first action is to sit the client up to
lower the blood pressure, then remove the noxious stimulus (most
commonly a full bladder or fecal impaction). Checking the bladder is
the next step, but raising the HOB is the immediate priority to
prevent stroke or hemorrhage.
4. A nurse is caring for a client with increased intracranial pressure
(ICP). Which of the following interventions should the nurse
implement?
A. Keep the client in a flat supine position
B. Perform frequent suctioning
C. Maintain the head of the bed at 30 degrees
D. Encourage the Valsalva maneuver
Answer: C. Maintain the head of the bed at 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes
venous outflow from the brain, helping to reduce ICP. Flat
positioning, suctioning, and the Valsalva maneuver all increase ICP
and should be avoided.
5. A client presents to the ER with a severe headache, nuchal
rigidity, and photophobia. Which of the following precautions
should the nurse initiate?
A. Airborne
Herzing (PDF) 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 nurse is assessing a client who has a closed head injury. The
client displays decorticate posturing. Which of the following
describes this posture?
A. Extension of both upper and lower extremities
B. Flexion of the upper extremities and extension of the lower
extremities
C. Extension of the upper extremities and flexion of the lower
extremities
D. Flaccid paralysis of all extremities
Answer: B. Flexion of the upper extremities and extension of the
lower extremities
Rationale: Decorticate posturing (abnormal flexion) indicates
damage to the cerebral hemispheres or internal capsule. The arms
are flexed tightly to the core, and the legs are extended.
Decerebrate posturing (Option A) indicates damage to the brainstem
and involves extension of both upper and lower extremities.
2. A client is admitted with a suspected cerebrovascular accident
(CVA). The nurse knows that the window of opportunity for
administering alteplase (tPA) is within how many hours of symptom
onset?
A. 1.5 hours
B. 3 hours
C. 6 hours
D. 12 hours
Answer: B. 3 hours
Rationale: Alteplase is a thrombolytic agent used to dissolve the clot
in an ischemic stroke. It must be administered within 3 to 4.5 hours
of the onset of symptoms to be effective and reduce the risk of
hemorrhagic transformation.
, 3. A client who suffered a spinal cord injury at the T6 level
complains of a severe, pounding headache. The nurse notes the
client is diaphoretic and has a blood pressure of 210/120 mm Hg.
Which of the following actions should the nurse take first?
A. Administer acetaminophen
B. Check the bladder for distention
C. Elevate the head of the bed
D. Prepare to administer IV nitroprusside
Answer: C. Elevate the head of the bed
Rationale: This client is experiencing autonomic dysreflexia, a life-
threatening emergency. The first action is to sit the client up to
lower the blood pressure, then remove the noxious stimulus (most
commonly a full bladder or fecal impaction). Checking the bladder is
the next step, but raising the HOB is the immediate priority to
prevent stroke or hemorrhage.
4. A nurse is caring for a client with increased intracranial pressure
(ICP). Which of the following interventions should the nurse
implement?
A. Keep the client in a flat supine position
B. Perform frequent suctioning
C. Maintain the head of the bed at 30 degrees
D. Encourage the Valsalva maneuver
Answer: C. Maintain the head of the bed at 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes
venous outflow from the brain, helping to reduce ICP. Flat
positioning, suctioning, and the Valsalva maneuver all increase ICP
and should be avoided.
5. A client presents to the ER with a severe headache, nuchal
rigidity, and photophobia. Which of the following precautions
should the nurse initiate?
A. Airborne
