NUR 265 Exam 3 Medical-Surgical Nursing | Galen College of Nursing 2026/2027 Verified Answers
NUR 265 Exam 3 Study Guide
Medical-Surgical Nursing
Questions and Answers with Verified Rationales
110 Questions · 6 Competency Sections · 75% Scenario-Based · 2026/2027 Latest Update
Exam Overview: This study guide is organized into six competency-aligned sections covering the NUR 265
Exam 3 blueprint: (1) Neurological Disorders; (2) Sensory and Neuromuscular Disorders; (3) Renal and Urinary
Disorders; (4) Endocrine Disorders; (5) Gastrointestinal and Hepatic Disorders; and (6) Emergency, Critical
Care, and Prioritization. Each question is multiple choice with four options (A-D) and exactly one correct
answer. Cognitive demand is distributed approximately 30% recall, 50% application, and 20% analysis.
Rationales double as study guide content, identifying the correct option and contrasting common
medical-surgical nursing misconceptions represented in distractors.
Section Map: Q1-20 Neurological Disorders (Stroke, TBI, Seizures, Increased ICP) · Q21-36 Sensory and
Neuromuscular Disorders (SCI, GBS, MG, Parkinson's) · Q37-56 Renal and Urinary Disorders (AKI, CKD,
Dialysis, UTI, Stones, BPH) · Q57-76 Endocrine Disorders (Diabetes, Thyroid, Adrenal, Pituitary) · Q77-94 GI
and Hepatic Disorders (Bleeding, Pancreatitis, Liver Failure, IBD) · Q95-110 Emergency, Critical Care, and
Prioritization (Shock, Sepsis, RSI, ABCs).
Verified Answer Note: Each rationale embeds confirmation against current AHA/ASA stroke guidelines, Brain
Trauma Foundation TBI guidelines, KDIGO AKI guidelines, ADA Standards of Care 2024, Surviving Sepsis
Campaign 2021, and current medical-surgical nursing standards. Commonly confused condition pairs (DKA vs.
HHS, SIADH vs. Diabetes Insipidus, Crohn's vs. Ulcerative Colitis, Myasthenic vs. Cholinergic Crisis, Prerenal
vs. Intrarenal AKI, Hemorrhagic vs. Ischemic Stroke) are explicitly addressed in distractor explanations.
Section 1: Neurological Disorders (Stroke, TBI, Seizures, & Increased ICP)
Q1. [Application] A 68-year-old arrives in the ED 90 minutes after sudden right-sided weakness and slurred
speech. CT scan shows no hemorrhage. Which action should the nurse anticipate next per stroke protocol?
A. Administer IV alteplase (tPA) within 3 hours (or 4.5 hours per extended window) of symptom onset,
after confirming no hemorrhage on CT and verifying exclusion criteria (no recent surgery, no anticoagulant
use, BP <185/110). [CORRECT]
B. Administer aspirin 325 mg orally immediately to prevent clot extension.
C. Administer IV labetalol to lower BP to 120/70.
D. Initiate therapeutic hypothermia to 33°C for 24 hours.
Correct Answer: A
Rationale: Alteplase (tPA) is indicated for acute ischemic stroke within 3 hours (FDA) or 4.5 hours (extended
AHA/ASA criteria) of symptom onset, provided CT excludes hemorrhage and exclusion criteria are met. BP must
be ≤185/110 before and ≤180/105 after tPA. Aspirin is given later, not immediately. Galen NUR 265 Exam 3
emphasizes the tPA window and exclusion criteria.
Page 1
,NUR 265 Exam 3 Medical-Surgical Nursing | Galen College of Nursing 2026/2027 Verified Answers
Q2. [Recall] Which of the following is an EXCLUSION criterion for IV alteplase (tPA) administration in acute
ischemic stroke?
A. Blood pressure of 140/85 mmHg.
B. Onset of symptoms 2 hours ago.
C. Recent intracranial hemorrhage, intracranial surgery, or significant head trauma within 3 months; active
bleeding; INR >1.7 or platelets <100,000; recent surgery or GI bleed within 14-21 days; or blood pressure
persistently >185/110 mmHg despite antihypertensive therapy. [CORRECT]
D. Glucose 140 mg/dL.
Correct Answer: C
Rationale: Absolute exclusion criteria for IV tPA include recent intracranial hemorrhage/surgery/trauma, active
bleeding, elevated INR (>1.7), low platelets, recent surgery/GI bleed, and uncontrolled hypertension (>185/110).
Glucose 140 mg/dL is not an exclusion; tPA must be given within 3 hours (or 4.5 hours extended). Galen NUR 265
Exam 3 emphasizes these safety criteria.
Q3. [Application] A patient receiving IV alteplase for ischemic stroke suddenly develops acute angioedema,
wheezing, and hypotension 20 minutes into the infusion. Which priority action should the nurse take?
A. Increase the infusion rate to complete it sooner.
B. Continue the infusion and recheck vitals in 15 minutes.
C. Stop the alteplase infusion immediately, notify the provider, ensure airway patency, and prepare to
administer antihistamines, corticosteroids, and epinephrine per anaphylaxis protocol. [CORRECT]
D. Administer IV labetalol to lower blood pressure.
Correct Answer: C
Rationale: Angioedema/anaphylaxis is a life-threatening alteplase reaction; the nurse must STOP the infusion,
ensure airway patency, notify the provider, and prepare antihistamines, corticosteroids, and epinephrine.
Continuing the infusion is contraindicated. Galen NUR 265 Exam 3 emphasizes emergency recognition during tPA
administration.
Q4. [Recall] The National Institutes of Health Stroke Scale (NIHSS) is best described as:
A. A 100-point scale measuring stroke recovery outcomes at 90 days.
B. A radiographic measure of infarct size on CT.
C. A standardized 15-item, 42-point neurologic exam assessing level of consciousness, gaze, visual fields,
facial palsy, motor arm/leg strength, ataxia, sensation, language, dysarthria, and extinction/inattention; used
to quantify stroke severity, tPA eligibility, and monitor progression. [CORRECT]
D. A 10-point scale for pain assessment.
Correct Answer: C
Rationale: NIHSS is a 15-item, 42-point standardized neurologic exam used to quantify stroke severity; scores >20
are severe and may indicate basilar or large MCA strokes. Galen NUR 265 Exam 3 includes NIHSS components
and clinical application.
Q5. [Application] A patient with hemorrhagic stroke has a BP of 210/115 mmHg. Which goal is most
appropriate per AHA/ASA guidance?
A. Maintain BP at baseline to ensure cerebral perfusion.
B. Administer IV fluids to dilute the bleed.
C. Lower SBP to 100 mmHg rapidly to reduce bleeding.
D. Lower SBP to 140-160 mmHg (target 140) using titratable IV antihypertensives (labetalol, nicardipine,
clevidipine); aggressive lowering below 130 may worsen ischemia, but sustained >160 increases hematoma
expansion. [CORRECT]
Correct Answer: D
Page 2
,NUR 265 Exam 3 Medical-Surgical Nursing | Galen College of Nursing 2026/2027 Verified Answers
Rationale: In hemorrhagic stroke, sustained SBP >160 mmHg promotes hematoma expansion. AHA/ASA targets
SBP 140 mmHg (140-160 acceptable) using titratable IV agents (nicardipine, labetalol, clevidipine). Aggressive
lowering below 130 risks cerebral ischemia. Galen NUR 265 Exam 3 emphasizes differential BP targets for
ischemic vs. hemorrhagic stroke.
Q6. [Application] A patient with increased ICP from a traumatic brain injury has the head of the bed flat at 0°.
The nurse notes decreasing level of consciousness. Which priority intervention should the nurse implement?
A. Administer IV fluids rapidly to dilute intracranial pressure.
B. Lower the head of the bed further to Trendelenburg.
C. Place the patient in Trendelenburg position.
D. Elevate the head of the bed to 30-45° and maintain the head in neutral alignment to promote venous
drainage and reduce ICP, while monitoring for hypotension (avoid lowering MAP below 65 to maintain
cerebral perfusion pressure). [CORRECT]
Correct Answer: D
Rationale: HOB elevation 30-45° with neutral head alignment promotes jugular venous drainage, reduces ICP, and
maintains CPP (CPP = MAP - ICP; target 60-70 mmHg). Trendelenburg increases ICP and is contraindicated.
Galen NUR 265 Exam 3 emphasizes positioning for ICP management.
Q7. [Recall] Cushing's triad, a late sign of increased ICP and impending herniation, is characterized by:
A. Hypertension with narrowed pulse pressure, tachycardia, and apnea.
B. Hypotension, bradycardia, and rapid shallow respirations.
C. Hypertension with widened pulse pressure, bradycardia, and irregular respirations (Cheyne-Stokes or
ataxic). [CORRECT]
D. Hypotension, tachycardia, and Kussmaul respirations.
Correct Answer: C
Rationale: Cushing's triad (hypertension with widened pulse pressure, bradycardia, irregular respirations) is a
LATE sign of increased ICP indicating impending brainstem herniation; immediate intervention is required. Galen
NUR 265 Exam 3 includes Cushing's triad as a critical assessment.
Q8. [Analysis] A patient with severe TBI develops unilateral pupillary dilation (6 mm) and nonreactivity, with
contralateral hemiparesis. These findings suggest:
A. Uncal herniation—compression of the third cranial nerve (oculomotor) ipsilateral to the lesion produces
pupil dilation and ptosis; the ipsilateral cerebral peduncle compression causes contralateral hemiparesis.
Emergency surgical decompression is indicated. [CORRECT]
B. Improvement of brain injury.
C. Cortical stroke only.
D. Spinal cord compression.
Correct Answer: A
Rationale: Unilateral fixed and dilated pupil with contralateral hemiparesis suggests uncal herniation compressing
CN III; emergency decompression (e.g., craniotomy) is required. Galen NUR 265 Exam 3 includes herniation
syndromes and emergency recognition.
Q9. [Application] A patient with a severe TBI and ICP monitor shows ICP of 25 mmHg. The provider orders IV
mannitol 0.5 g/kg. Which assessment finding requires immediate discontinuation of the infusion?
A. Mild decrease in urine output.
B. Blood pressure 110/70.
C. Slight headache.
D. Acute pulmonary edema or acute decompensated heart failure—mannitol mobilizes intravascular
volume and is contraindicated in pulmonary edema/CHF. Serum osmolality should remain <320 mOsm/kg;
Page 3
, NUR 265 Exam 3 Medical-Surgical Nursing | Galen College of Nursing 2026/2027 Verified Answers
anuria, hypovolemia, and hyperosmolarity require careful monitoring. [CORRECT]
Correct Answer: D
Rationale: Mannitol is an osmotic diuretic that mobilizes fluid into the intravascular space and is contraindicated
in pulmonary edema/CHF due to acute volume overload. Monitor serum osmolality (<320 mOsm/kg), urine output,
and electrolytes. Galen NUR 265 Exam 3 includes mannitol administration safety.
Q10. [Recall] A normal ICP reading in an adult is approximately:
A. 20-30 mmHg.
B. 30-40 mmHg.
C. Greater than 40 mmHg.
D. 0-10 mmHg (typically 5-15 mmHg is normal; >20 mmHg is generally considered elevated, requiring
treatment in TBI per Brain Trauma Foundation guidelines). [CORRECT]
Correct Answer: D
Rationale: Normal ICP is 5-15 mmHg in adults; values >20-25 mmHg are considered elevated and warrant
treatment per Brain Trauma Foundation guidelines. CPP = MAP - ICP (target 60-70 mmHg). Galen NUR 265
Exam 3 includes ICP monitoring parameters.
Q11. [Application] A patient on the neuro unit has a generalized tonic-clonic seizure lasting 90 seconds,
followed by another seizure without regaining consciousness. Which priority nursing action is indicated?
A. Recognize status epilepticus (continuous seizure ≥5 minutes or recurrent seizures without recovery of
consciousness) and initiate emergency protocol: protect airway, position lateral recumbent, administer IV
lorazepam (Ativan) 0.1 mg/kg (max 4 mg), and prepare to escalate to second-line agents (fosphenytoin,
levetiracetam). [CORRECT]
B. Restrain the patient to prevent self-harm.
C. Wait and observe for spontaneous resolution.
D. Administer oral phenytoin immediately.
Correct Answer: A
Rationale: Status epilepticus is continuous seizure ≥5 minutes or recurrent without recovery; emergency
management is airway protection, lateral positioning, IV lorazepam (first-line benzodiazepine), and second-line
agents (fosphenytoin, valproate, levetiracetam). Restraints are contraindicated. Galen NUR 265 Exam 3 includes
status epilepticus protocol.
Q12. [Recall] Which antiepileptic drug is commonly used as first-line for generalized tonic-clonic seizures and
requires monitoring for rash (Stevens-Johnson syndrome), especially in patients of Asian ancestry with
HLA-B*1502?
A. Carbamazepine, a sodium channel blocker effective for partial and generalized tonic-clonic seizures;
HLA-B*1502 carriage (especially in Han Chinese, Thai, and other Asian populations) increases risk of
SJS/TEN. [CORRECT]
B. Ethosuximide.
C. Gabapentin.
D. Topiramate.
Correct Answer: A
Rationale: Carbamazepine is a first-line agent for partial and generalized tonic-clonic seizures; HLA-B*1502
carriage (Asian ancestry) is strongly associated with SJS/TEN. Galen NUR 265 Exam 3 includes antiepileptic
safety and genetic considerations.
Q13. [Application] A patient receiving IV phenytoin for seizure prophylaxis reports burning at the IV site. The
IV pump shows the infusion rate was set to 100 mg/min. Which nursing action is most appropriate?
A. Apply cold compress to the IV site.
Page 4
NUR 265 Exam 3 Study Guide
Medical-Surgical Nursing
Questions and Answers with Verified Rationales
110 Questions · 6 Competency Sections · 75% Scenario-Based · 2026/2027 Latest Update
Exam Overview: This study guide is organized into six competency-aligned sections covering the NUR 265
Exam 3 blueprint: (1) Neurological Disorders; (2) Sensory and Neuromuscular Disorders; (3) Renal and Urinary
Disorders; (4) Endocrine Disorders; (5) Gastrointestinal and Hepatic Disorders; and (6) Emergency, Critical
Care, and Prioritization. Each question is multiple choice with four options (A-D) and exactly one correct
answer. Cognitive demand is distributed approximately 30% recall, 50% application, and 20% analysis.
Rationales double as study guide content, identifying the correct option and contrasting common
medical-surgical nursing misconceptions represented in distractors.
Section Map: Q1-20 Neurological Disorders (Stroke, TBI, Seizures, Increased ICP) · Q21-36 Sensory and
Neuromuscular Disorders (SCI, GBS, MG, Parkinson's) · Q37-56 Renal and Urinary Disorders (AKI, CKD,
Dialysis, UTI, Stones, BPH) · Q57-76 Endocrine Disorders (Diabetes, Thyroid, Adrenal, Pituitary) · Q77-94 GI
and Hepatic Disorders (Bleeding, Pancreatitis, Liver Failure, IBD) · Q95-110 Emergency, Critical Care, and
Prioritization (Shock, Sepsis, RSI, ABCs).
Verified Answer Note: Each rationale embeds confirmation against current AHA/ASA stroke guidelines, Brain
Trauma Foundation TBI guidelines, KDIGO AKI guidelines, ADA Standards of Care 2024, Surviving Sepsis
Campaign 2021, and current medical-surgical nursing standards. Commonly confused condition pairs (DKA vs.
HHS, SIADH vs. Diabetes Insipidus, Crohn's vs. Ulcerative Colitis, Myasthenic vs. Cholinergic Crisis, Prerenal
vs. Intrarenal AKI, Hemorrhagic vs. Ischemic Stroke) are explicitly addressed in distractor explanations.
Section 1: Neurological Disorders (Stroke, TBI, Seizures, & Increased ICP)
Q1. [Application] A 68-year-old arrives in the ED 90 minutes after sudden right-sided weakness and slurred
speech. CT scan shows no hemorrhage. Which action should the nurse anticipate next per stroke protocol?
A. Administer IV alteplase (tPA) within 3 hours (or 4.5 hours per extended window) of symptom onset,
after confirming no hemorrhage on CT and verifying exclusion criteria (no recent surgery, no anticoagulant
use, BP <185/110). [CORRECT]
B. Administer aspirin 325 mg orally immediately to prevent clot extension.
C. Administer IV labetalol to lower BP to 120/70.
D. Initiate therapeutic hypothermia to 33°C for 24 hours.
Correct Answer: A
Rationale: Alteplase (tPA) is indicated for acute ischemic stroke within 3 hours (FDA) or 4.5 hours (extended
AHA/ASA criteria) of symptom onset, provided CT excludes hemorrhage and exclusion criteria are met. BP must
be ≤185/110 before and ≤180/105 after tPA. Aspirin is given later, not immediately. Galen NUR 265 Exam 3
emphasizes the tPA window and exclusion criteria.
Page 1
,NUR 265 Exam 3 Medical-Surgical Nursing | Galen College of Nursing 2026/2027 Verified Answers
Q2. [Recall] Which of the following is an EXCLUSION criterion for IV alteplase (tPA) administration in acute
ischemic stroke?
A. Blood pressure of 140/85 mmHg.
B. Onset of symptoms 2 hours ago.
C. Recent intracranial hemorrhage, intracranial surgery, or significant head trauma within 3 months; active
bleeding; INR >1.7 or platelets <100,000; recent surgery or GI bleed within 14-21 days; or blood pressure
persistently >185/110 mmHg despite antihypertensive therapy. [CORRECT]
D. Glucose 140 mg/dL.
Correct Answer: C
Rationale: Absolute exclusion criteria for IV tPA include recent intracranial hemorrhage/surgery/trauma, active
bleeding, elevated INR (>1.7), low platelets, recent surgery/GI bleed, and uncontrolled hypertension (>185/110).
Glucose 140 mg/dL is not an exclusion; tPA must be given within 3 hours (or 4.5 hours extended). Galen NUR 265
Exam 3 emphasizes these safety criteria.
Q3. [Application] A patient receiving IV alteplase for ischemic stroke suddenly develops acute angioedema,
wheezing, and hypotension 20 minutes into the infusion. Which priority action should the nurse take?
A. Increase the infusion rate to complete it sooner.
B. Continue the infusion and recheck vitals in 15 minutes.
C. Stop the alteplase infusion immediately, notify the provider, ensure airway patency, and prepare to
administer antihistamines, corticosteroids, and epinephrine per anaphylaxis protocol. [CORRECT]
D. Administer IV labetalol to lower blood pressure.
Correct Answer: C
Rationale: Angioedema/anaphylaxis is a life-threatening alteplase reaction; the nurse must STOP the infusion,
ensure airway patency, notify the provider, and prepare antihistamines, corticosteroids, and epinephrine.
Continuing the infusion is contraindicated. Galen NUR 265 Exam 3 emphasizes emergency recognition during tPA
administration.
Q4. [Recall] The National Institutes of Health Stroke Scale (NIHSS) is best described as:
A. A 100-point scale measuring stroke recovery outcomes at 90 days.
B. A radiographic measure of infarct size on CT.
C. A standardized 15-item, 42-point neurologic exam assessing level of consciousness, gaze, visual fields,
facial palsy, motor arm/leg strength, ataxia, sensation, language, dysarthria, and extinction/inattention; used
to quantify stroke severity, tPA eligibility, and monitor progression. [CORRECT]
D. A 10-point scale for pain assessment.
Correct Answer: C
Rationale: NIHSS is a 15-item, 42-point standardized neurologic exam used to quantify stroke severity; scores >20
are severe and may indicate basilar or large MCA strokes. Galen NUR 265 Exam 3 includes NIHSS components
and clinical application.
Q5. [Application] A patient with hemorrhagic stroke has a BP of 210/115 mmHg. Which goal is most
appropriate per AHA/ASA guidance?
A. Maintain BP at baseline to ensure cerebral perfusion.
B. Administer IV fluids to dilute the bleed.
C. Lower SBP to 100 mmHg rapidly to reduce bleeding.
D. Lower SBP to 140-160 mmHg (target 140) using titratable IV antihypertensives (labetalol, nicardipine,
clevidipine); aggressive lowering below 130 may worsen ischemia, but sustained >160 increases hematoma
expansion. [CORRECT]
Correct Answer: D
Page 2
,NUR 265 Exam 3 Medical-Surgical Nursing | Galen College of Nursing 2026/2027 Verified Answers
Rationale: In hemorrhagic stroke, sustained SBP >160 mmHg promotes hematoma expansion. AHA/ASA targets
SBP 140 mmHg (140-160 acceptable) using titratable IV agents (nicardipine, labetalol, clevidipine). Aggressive
lowering below 130 risks cerebral ischemia. Galen NUR 265 Exam 3 emphasizes differential BP targets for
ischemic vs. hemorrhagic stroke.
Q6. [Application] A patient with increased ICP from a traumatic brain injury has the head of the bed flat at 0°.
The nurse notes decreasing level of consciousness. Which priority intervention should the nurse implement?
A. Administer IV fluids rapidly to dilute intracranial pressure.
B. Lower the head of the bed further to Trendelenburg.
C. Place the patient in Trendelenburg position.
D. Elevate the head of the bed to 30-45° and maintain the head in neutral alignment to promote venous
drainage and reduce ICP, while monitoring for hypotension (avoid lowering MAP below 65 to maintain
cerebral perfusion pressure). [CORRECT]
Correct Answer: D
Rationale: HOB elevation 30-45° with neutral head alignment promotes jugular venous drainage, reduces ICP, and
maintains CPP (CPP = MAP - ICP; target 60-70 mmHg). Trendelenburg increases ICP and is contraindicated.
Galen NUR 265 Exam 3 emphasizes positioning for ICP management.
Q7. [Recall] Cushing's triad, a late sign of increased ICP and impending herniation, is characterized by:
A. Hypertension with narrowed pulse pressure, tachycardia, and apnea.
B. Hypotension, bradycardia, and rapid shallow respirations.
C. Hypertension with widened pulse pressure, bradycardia, and irregular respirations (Cheyne-Stokes or
ataxic). [CORRECT]
D. Hypotension, tachycardia, and Kussmaul respirations.
Correct Answer: C
Rationale: Cushing's triad (hypertension with widened pulse pressure, bradycardia, irregular respirations) is a
LATE sign of increased ICP indicating impending brainstem herniation; immediate intervention is required. Galen
NUR 265 Exam 3 includes Cushing's triad as a critical assessment.
Q8. [Analysis] A patient with severe TBI develops unilateral pupillary dilation (6 mm) and nonreactivity, with
contralateral hemiparesis. These findings suggest:
A. Uncal herniation—compression of the third cranial nerve (oculomotor) ipsilateral to the lesion produces
pupil dilation and ptosis; the ipsilateral cerebral peduncle compression causes contralateral hemiparesis.
Emergency surgical decompression is indicated. [CORRECT]
B. Improvement of brain injury.
C. Cortical stroke only.
D. Spinal cord compression.
Correct Answer: A
Rationale: Unilateral fixed and dilated pupil with contralateral hemiparesis suggests uncal herniation compressing
CN III; emergency decompression (e.g., craniotomy) is required. Galen NUR 265 Exam 3 includes herniation
syndromes and emergency recognition.
Q9. [Application] A patient with a severe TBI and ICP monitor shows ICP of 25 mmHg. The provider orders IV
mannitol 0.5 g/kg. Which assessment finding requires immediate discontinuation of the infusion?
A. Mild decrease in urine output.
B. Blood pressure 110/70.
C. Slight headache.
D. Acute pulmonary edema or acute decompensated heart failure—mannitol mobilizes intravascular
volume and is contraindicated in pulmonary edema/CHF. Serum osmolality should remain <320 mOsm/kg;
Page 3
, NUR 265 Exam 3 Medical-Surgical Nursing | Galen College of Nursing 2026/2027 Verified Answers
anuria, hypovolemia, and hyperosmolarity require careful monitoring. [CORRECT]
Correct Answer: D
Rationale: Mannitol is an osmotic diuretic that mobilizes fluid into the intravascular space and is contraindicated
in pulmonary edema/CHF due to acute volume overload. Monitor serum osmolality (<320 mOsm/kg), urine output,
and electrolytes. Galen NUR 265 Exam 3 includes mannitol administration safety.
Q10. [Recall] A normal ICP reading in an adult is approximately:
A. 20-30 mmHg.
B. 30-40 mmHg.
C. Greater than 40 mmHg.
D. 0-10 mmHg (typically 5-15 mmHg is normal; >20 mmHg is generally considered elevated, requiring
treatment in TBI per Brain Trauma Foundation guidelines). [CORRECT]
Correct Answer: D
Rationale: Normal ICP is 5-15 mmHg in adults; values >20-25 mmHg are considered elevated and warrant
treatment per Brain Trauma Foundation guidelines. CPP = MAP - ICP (target 60-70 mmHg). Galen NUR 265
Exam 3 includes ICP monitoring parameters.
Q11. [Application] A patient on the neuro unit has a generalized tonic-clonic seizure lasting 90 seconds,
followed by another seizure without regaining consciousness. Which priority nursing action is indicated?
A. Recognize status epilepticus (continuous seizure ≥5 minutes or recurrent seizures without recovery of
consciousness) and initiate emergency protocol: protect airway, position lateral recumbent, administer IV
lorazepam (Ativan) 0.1 mg/kg (max 4 mg), and prepare to escalate to second-line agents (fosphenytoin,
levetiracetam). [CORRECT]
B. Restrain the patient to prevent self-harm.
C. Wait and observe for spontaneous resolution.
D. Administer oral phenytoin immediately.
Correct Answer: A
Rationale: Status epilepticus is continuous seizure ≥5 minutes or recurrent without recovery; emergency
management is airway protection, lateral positioning, IV lorazepam (first-line benzodiazepine), and second-line
agents (fosphenytoin, valproate, levetiracetam). Restraints are contraindicated. Galen NUR 265 Exam 3 includes
status epilepticus protocol.
Q12. [Recall] Which antiepileptic drug is commonly used as first-line for generalized tonic-clonic seizures and
requires monitoring for rash (Stevens-Johnson syndrome), especially in patients of Asian ancestry with
HLA-B*1502?
A. Carbamazepine, a sodium channel blocker effective for partial and generalized tonic-clonic seizures;
HLA-B*1502 carriage (especially in Han Chinese, Thai, and other Asian populations) increases risk of
SJS/TEN. [CORRECT]
B. Ethosuximide.
C. Gabapentin.
D. Topiramate.
Correct Answer: A
Rationale: Carbamazepine is a first-line agent for partial and generalized tonic-clonic seizures; HLA-B*1502
carriage (Asian ancestry) is strongly associated with SJS/TEN. Galen NUR 265 Exam 3 includes antiepileptic
safety and genetic considerations.
Q13. [Application] A patient receiving IV phenytoin for seizure prophylaxis reports burning at the IV site. The
IV pump shows the infusion rate was set to 100 mg/min. Which nursing action is most appropriate?
A. Apply cold compress to the IV site.
Page 4
