NUR 254 - MEDICAL-SURGICAL NURSING II -FINAL
EXAM 4 2026/2027 – 70 Questions & Answers 100%
OVERVIEW
Final Exam covers comprehensive Med-Surg II: Units 11-14: Neurology - stroke,
increased ICP, seizures; Sensory - cataracts, glaucoma; Shock & Sepsis - hypovolemic,
cardiogenic, septic, anaphylactic; Critical Care & Emergency - ARDS, MODS, triage,
burns, trauma. Emphasis on ABCs, neuro checks, early recognition of deterioration,
hemodynamic monitoring, infection control, and emergency interventions to prevent
death and disability in acutely ill adult patients. Correct answers bold Green.
TOPICS COVERED:
Unit 11: Neuro Q1-20
Unit 12: Sensory Q21-30
Unit 13: Shock/Sepsis/Critical Care Q31-55
Unit 14: Emergency/Burns/Trauma Q56-70
UNIT 11: NEUROLOGY Q1-20
1. Increased ICP early signs are:
A. Headache, nausea, change in LOC, restlessness, slight change in pupils
B. Cushing's triad only
C. No signs
D. Fixed pupils only
Rationale: Early brain compression signs.
2. Cushing's triad for increased ICP is:
A. Low BP, high HR, fever
B. High BP, bradycardia, bradypnea
C. Low BP, bradycardia, tachypnea
D. Hypertension with wide pulse pressure, bradycardia, irregular respirations -
late sign
Rationale: Brainstem herniation late.
3. Stroke - BEFAST stands for:
A. Only face and arms
B. Breathing, Eyes, Face
C. No acronym needed
D. Balance, Eyes, Face droop, Arm drift, Speech, Time
Rationale: Stroke recognition.
, 4. Ischemic stroke tPA window is:
A. 24 hours
B. No window
C. Anytime if bleeding
D. Within 3-4.5 hrs after onset after CT rules out hemorrhage, BP <185/110
Rationale: Time is brain.
5. Hemorrhagic stroke care includes:
A. No tPA, control bleeding, lower ICP, quiet dark room, control HTN, HOB 30 deg
B. Give tPA immediately
C. Give heparin
D. No BP control needed
Rationale: Bleeding needs control.
6. Seizure - during seizure nurse should NOT:
A. Protect from injury
B. Time seizure
C. Turn to side
D. Put object in mouth, restrain, give food/water
Rationale: Causes injury and aspiration.
7. Status epilepticus is:
A. One brief seizure
B. Absence seizure only
C. No emergency
D. Seizure >5 min or repeated without recovery - give lorazepam IV, airway
Rationale: Emergency risk brain damage.
8. Postictal phase is:
A. Before seizure aura
B. No confusion
C. Only during seizure
D. After seizure - confusion, drowsiness, headache, muscle aches
Rationale: Recovery period.
9. Meningitis signs include:
A. No nuchal rigidity
B. No fever
C. Only leg pain
D. Fever, headache, nuchal rigidity, photophobia, positive Kernig and Brudzinski
Rationale: Meningeal irritation.
10. Lumbar puncture contraindicated in:
A. Meningitis suspected
B. No contraindications
C. Only back pain
D. Increased ICP, bleeding disorder, infection at site - risk herniation
Rationale: Pressure gradient causes herniation.
11. Autonomic dysreflexia trigger is:
A. Empty bladder
B. Loose clothes
C. No stimulus
EXAM 4 2026/2027 – 70 Questions & Answers 100%
OVERVIEW
Final Exam covers comprehensive Med-Surg II: Units 11-14: Neurology - stroke,
increased ICP, seizures; Sensory - cataracts, glaucoma; Shock & Sepsis - hypovolemic,
cardiogenic, septic, anaphylactic; Critical Care & Emergency - ARDS, MODS, triage,
burns, trauma. Emphasis on ABCs, neuro checks, early recognition of deterioration,
hemodynamic monitoring, infection control, and emergency interventions to prevent
death and disability in acutely ill adult patients. Correct answers bold Green.
TOPICS COVERED:
Unit 11: Neuro Q1-20
Unit 12: Sensory Q21-30
Unit 13: Shock/Sepsis/Critical Care Q31-55
Unit 14: Emergency/Burns/Trauma Q56-70
UNIT 11: NEUROLOGY Q1-20
1. Increased ICP early signs are:
A. Headache, nausea, change in LOC, restlessness, slight change in pupils
B. Cushing's triad only
C. No signs
D. Fixed pupils only
Rationale: Early brain compression signs.
2. Cushing's triad for increased ICP is:
A. Low BP, high HR, fever
B. High BP, bradycardia, bradypnea
C. Low BP, bradycardia, tachypnea
D. Hypertension with wide pulse pressure, bradycardia, irregular respirations -
late sign
Rationale: Brainstem herniation late.
3. Stroke - BEFAST stands for:
A. Only face and arms
B. Breathing, Eyes, Face
C. No acronym needed
D. Balance, Eyes, Face droop, Arm drift, Speech, Time
Rationale: Stroke recognition.
, 4. Ischemic stroke tPA window is:
A. 24 hours
B. No window
C. Anytime if bleeding
D. Within 3-4.5 hrs after onset after CT rules out hemorrhage, BP <185/110
Rationale: Time is brain.
5. Hemorrhagic stroke care includes:
A. No tPA, control bleeding, lower ICP, quiet dark room, control HTN, HOB 30 deg
B. Give tPA immediately
C. Give heparin
D. No BP control needed
Rationale: Bleeding needs control.
6. Seizure - during seizure nurse should NOT:
A. Protect from injury
B. Time seizure
C. Turn to side
D. Put object in mouth, restrain, give food/water
Rationale: Causes injury and aspiration.
7. Status epilepticus is:
A. One brief seizure
B. Absence seizure only
C. No emergency
D. Seizure >5 min or repeated without recovery - give lorazepam IV, airway
Rationale: Emergency risk brain damage.
8. Postictal phase is:
A. Before seizure aura
B. No confusion
C. Only during seizure
D. After seizure - confusion, drowsiness, headache, muscle aches
Rationale: Recovery period.
9. Meningitis signs include:
A. No nuchal rigidity
B. No fever
C. Only leg pain
D. Fever, headache, nuchal rigidity, photophobia, positive Kernig and Brudzinski
Rationale: Meningeal irritation.
10. Lumbar puncture contraindicated in:
A. Meningitis suspected
B. No contraindications
C. Only back pain
D. Increased ICP, bleeding disorder, infection at site - risk herniation
Rationale: Pressure gradient causes herniation.
11. Autonomic dysreflexia trigger is:
A. Empty bladder
B. Loose clothes
C. No stimulus
