NUR 3250 Med-Surg Exam 3 Review –
Kahoot | 99 Questions, Verified
Answers & Detailed Rationales | Neuro
& Sensory | 2026/2027 Updated |
Galen College
SECTION 1: Neurological Assessment & Diagnostics (Questions 1–25)
1. A nurse is assessing a patient's level of consciousness using the Glasgow Coma
Scale (GCS). Which three areas are evaluated?
• A) Pupil size, blood pressure, and respiratory rate
• B) Eye opening, verbal response, and motor response
• C) Orientation, memory, and judgment
• D) Cranial nerve function, reflexes, and sensation
Correct Answer: B) Eye opening, verbal response, and motor response
Rationale: The Glasgow Coma Scale evaluates three components: eye opening
(1–4), verbal response (1–5), and motor response (1–6). The total score ranges
from 3 to 15. A score of 8 or less typically indicates severe neurological
impairment and possible need for airway protection. Pupil size, vital signs, and
cranial nerve function are part of a broader neuro assessment but are not
components of the GCS.
2. A patient presents with a sudden onset of the "worst headache of my life."
The nurse should suspect which condition?
, • A) Migraine headache
• B) Tension headache
• C) Subarachnoid hemorrhage
• D) Sinusitis
Correct Answer: C) Subarachnoid hemorrhage
Rationale: A sudden, severe "thunderclap" headache described as the "worst
headache of my life" is a classic presentation of subarachnoid hemorrhage (SAH),
often caused by a ruptured cerebral aneurysm. This is a medical emergency
requiring immediate CT scan and possible lumbar puncture. Migraines are
typically throbbing and unilateral, tension headaches are bilateral and band-like,
and sinusitis causes facial pressure pain.
3. Which diagnostic test is considered the gold standard for diagnosing an acute
ischemic stroke?
• A) CT scan without contrast
• B) MRI with diffusion-weighted imaging (DWI)
• C) Carotid Doppler ultrasound
• D) Electroencephalogram (EEG)
Correct Answer: A) CT scan without contrast
Rationale: A non-contrast CT scan is the first-line and gold standard imaging
study for acute stroke because it rapidly differentiates ischemic from hemorrhagic
stroke, which is critical for determining treatment (thrombolytics are
contraindicated in hemorrhagic stroke). MRI with DWI is more sensitive for early
ischemia but takes longer and is less readily available in the acute setting. Carotid
Doppler evaluates stenosis, and EEG evaluates seizure activity.
,4. A nurse is preparing a patient for a lumbar puncture. Which position should
the nurse assist the patient into?
• A) Prone with head turned to the side
• B) Side-lying with knees drawn to chest and chin tucked
• C) Supine with head elevated 45 degrees
• D) High Fowler's position
Correct Answer: B) Side-lying with knees drawn to chest and chin tucked
Rationale: The lateral decubitus position with flexion of the neck and knees
(fetal position) widens the spaces between the lumbar vertebrae, facilitating
needle insertion into the subarachnoid space. This position also helps prevent
post-procedure headache. Supine and Fowler's positions do not open the
vertebral spaces adequately.
5. After a lumbar puncture, the nurse should instruct the patient to remain in
which position to prevent post-lumbar puncture headache?
• A) High Fowler's for 6 hours
• B) Flat supine for 4–6 hours
• C) Side-lying for 2 hours
• D) Prone for 8 hours
Correct Answer: B) Flat supine for 4–6 hours
Rationale: Remaining flat (supine) for 4–6 hours after a lumbar puncture helps
prevent cerebrospinal fluid (CSF) leakage, which can cause a post-lumbar puncture
headache. The headache is typically worse when sitting or standing and relieved
when lying flat. Hydration is also encouraged to help replenish CSF volume.
, 6. Which assessment finding indicates increased intracranial pressure (ICP) in a
patient with a head injury?
• A) Blood pressure 90/50 mmHg
• B) Heart rate 120 bpm
• C) Widened pulse pressure with bradycardia
• D) Increased urine output
Correct Answer: C) Widened pulse pressure with bradycardia
Rationale: Cushing's triad—widened pulse pressure, bradycardia, and
irregular respirations—is a late sign of increased ICP. It results from compression
of the brainstem and activation of the sympathetic nervous system. Hypotension,
tachycardia, and increased urine output are not typical signs of increased ICP; in
fact, hypertension is more common due to compensatory mechanisms.
7. A nurse is assessing a patient with suspected meningitis. Which finding is
most indicative of meningeal irritation?
• A) Positive Babinski sign
• B) Nuchal rigidity and positive Kernig's sign
• C) Pupil dilation
• D) Ataxia
Correct Answer: B) Nuchal rigidity and positive Kernig's sign
Rationale: Nuchal rigidity (stiff neck) and positive Kernig's and Brudzinski's
signs are classic indicators of meningeal irritation seen in meningitis. Kernig's sign
is resistance to knee extension when the hip is flexed. Babinski sign indicates
upper motor neuron dysfunction, pupil dilation can indicate ICP, and ataxia
indicates cerebellar dysfunction.
Kahoot | 99 Questions, Verified
Answers & Detailed Rationales | Neuro
& Sensory | 2026/2027 Updated |
Galen College
SECTION 1: Neurological Assessment & Diagnostics (Questions 1–25)
1. A nurse is assessing a patient's level of consciousness using the Glasgow Coma
Scale (GCS). Which three areas are evaluated?
• A) Pupil size, blood pressure, and respiratory rate
• B) Eye opening, verbal response, and motor response
• C) Orientation, memory, and judgment
• D) Cranial nerve function, reflexes, and sensation
Correct Answer: B) Eye opening, verbal response, and motor response
Rationale: The Glasgow Coma Scale evaluates three components: eye opening
(1–4), verbal response (1–5), and motor response (1–6). The total score ranges
from 3 to 15. A score of 8 or less typically indicates severe neurological
impairment and possible need for airway protection. Pupil size, vital signs, and
cranial nerve function are part of a broader neuro assessment but are not
components of the GCS.
2. A patient presents with a sudden onset of the "worst headache of my life."
The nurse should suspect which condition?
, • A) Migraine headache
• B) Tension headache
• C) Subarachnoid hemorrhage
• D) Sinusitis
Correct Answer: C) Subarachnoid hemorrhage
Rationale: A sudden, severe "thunderclap" headache described as the "worst
headache of my life" is a classic presentation of subarachnoid hemorrhage (SAH),
often caused by a ruptured cerebral aneurysm. This is a medical emergency
requiring immediate CT scan and possible lumbar puncture. Migraines are
typically throbbing and unilateral, tension headaches are bilateral and band-like,
and sinusitis causes facial pressure pain.
3. Which diagnostic test is considered the gold standard for diagnosing an acute
ischemic stroke?
• A) CT scan without contrast
• B) MRI with diffusion-weighted imaging (DWI)
• C) Carotid Doppler ultrasound
• D) Electroencephalogram (EEG)
Correct Answer: A) CT scan without contrast
Rationale: A non-contrast CT scan is the first-line and gold standard imaging
study for acute stroke because it rapidly differentiates ischemic from hemorrhagic
stroke, which is critical for determining treatment (thrombolytics are
contraindicated in hemorrhagic stroke). MRI with DWI is more sensitive for early
ischemia but takes longer and is less readily available in the acute setting. Carotid
Doppler evaluates stenosis, and EEG evaluates seizure activity.
,4. A nurse is preparing a patient for a lumbar puncture. Which position should
the nurse assist the patient into?
• A) Prone with head turned to the side
• B) Side-lying with knees drawn to chest and chin tucked
• C) Supine with head elevated 45 degrees
• D) High Fowler's position
Correct Answer: B) Side-lying with knees drawn to chest and chin tucked
Rationale: The lateral decubitus position with flexion of the neck and knees
(fetal position) widens the spaces between the lumbar vertebrae, facilitating
needle insertion into the subarachnoid space. This position also helps prevent
post-procedure headache. Supine and Fowler's positions do not open the
vertebral spaces adequately.
5. After a lumbar puncture, the nurse should instruct the patient to remain in
which position to prevent post-lumbar puncture headache?
• A) High Fowler's for 6 hours
• B) Flat supine for 4–6 hours
• C) Side-lying for 2 hours
• D) Prone for 8 hours
Correct Answer: B) Flat supine for 4–6 hours
Rationale: Remaining flat (supine) for 4–6 hours after a lumbar puncture helps
prevent cerebrospinal fluid (CSF) leakage, which can cause a post-lumbar puncture
headache. The headache is typically worse when sitting or standing and relieved
when lying flat. Hydration is also encouraged to help replenish CSF volume.
, 6. Which assessment finding indicates increased intracranial pressure (ICP) in a
patient with a head injury?
• A) Blood pressure 90/50 mmHg
• B) Heart rate 120 bpm
• C) Widened pulse pressure with bradycardia
• D) Increased urine output
Correct Answer: C) Widened pulse pressure with bradycardia
Rationale: Cushing's triad—widened pulse pressure, bradycardia, and
irregular respirations—is a late sign of increased ICP. It results from compression
of the brainstem and activation of the sympathetic nervous system. Hypotension,
tachycardia, and increased urine output are not typical signs of increased ICP; in
fact, hypertension is more common due to compensatory mechanisms.
7. A nurse is assessing a patient with suspected meningitis. Which finding is
most indicative of meningeal irritation?
• A) Positive Babinski sign
• B) Nuchal rigidity and positive Kernig's sign
• C) Pupil dilation
• D) Ataxia
Correct Answer: B) Nuchal rigidity and positive Kernig's sign
Rationale: Nuchal rigidity (stiff neck) and positive Kernig's and Brudzinski's
signs are classic indicators of meningeal irritation seen in meningitis. Kernig's sign
is resistance to knee extension when the hip is flexed. Babinski sign indicates
upper motor neuron dysfunction, pupil dilation can indicate ICP, and ataxia
indicates cerebellar dysfunction.
