NU185 MEDICAL-SURGICAL
NURSING II COMPREHENSIVE FINAL
REVIEW 100% CORRECT QUESTION
MASTER TEST PREP
Master your advanced nursing curriculum with this comprehensive,
question practice exam meticulously tailored for the Galen College
NU 185 Medical-Surgical Nursing II course. Each high-yield
question features italicized correct answers and detailed bold-
italicized rationales covering critical topics like neurology,
advanced burn management, endocrine emergencies, ECG
interpretation, and complex acid-base balance. Designed as the
ultimate academic assessment tool, this resource guarantees
100% correct, expert-verified rationales to help you ace your
exams and secure top grades.
Unit 1: Advanced Neurological Nursing
(Questions 1–13)
Q1. A nurse is assessing a client who was
admitted with a severe traumatic brain injury.
Which clinical manifestation should the nurse
recognize as the earliest indicator of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Ipsilateral pupillary dilation
C. Change in the level of consciousness (LOC)
D. Decerebrate posturing
Answer: C
,Rationale: A change in the level of
consciousness (such as agitation, lethargy, or
confusion) is the most sensitive and earliest
indicator of deteriorating neurological status and
increasing ICP. Changes in vital signs (Cushing’s
triad) and abnormal posturing are late signs.
Q2. A client with a history of tonic-clonic seizures
is admitted to the medical-surgical unit. Which
nursing intervention is a priority during an active
seizure event?
A. Insert an oral airway to prevent tongue biting.
B. Turn the client onto their side to maintain airway
patency.
C. Restrain the client's extremities to prevent
fractures.
D. Administer oral phenytoin immediately.
Answer: B
Rationale: Turning the client onto their side is
essential to allow saliva or emesis to drain,
keeping the airway clear and preventing
aspiration. Objects should never be placed in the
mouth, and the client should never be restrained.
Q3. The nurse is caring for a client with a history
of epilepsy who suddenly stops taking their
prescribed levetiracetam. What life-threatening
complication is this client at highest risk for
,developing?
A. Autonomic dysreflexia
B. Myasthenic crisis
C. Status epilepticus
D. Ischemic stroke
Answer: C
Rationale: Abruptly discontinuing or omitting
antiepileptic medications drops the therapeutic
drug level precipitously, which can trigger status
epilepticus—a continuous state of seizure
activity lasting more than 5 minutes that
constitutes a medical emergency.
Q4. A client who experienced an ischemic stroke
3 hours ago is being evaluated for intravenous
tissue plasminogen activator (tPA) therapy.
Which assessment finding serves as an absolute
contraindication for tPA?
A. Total symptom duration of 3 hours
B. Blood pressure reading of 140/90 mm Hg
C. Platelet count of 220,000/mm³
D. History of an intracranial hemorrhage
Answer: D
Rationale: A previous history of intracranial
hemorrhage, active internal bleeding, recent
intracranial surgery, or severe uncontrolled
hypertension are absolute contraindications for
, tPA due to the catastrophic risk of systemic or
cerebral bleeding.
Q5. A nurse is caring for a client with a T4 spinal
cord injury. The client suddenly reports a severe,
pounding headache and has a blood pressure of
190/100 mm Hg. What is the priority nursing
action?
A. Administer an ordered PRN analgesic for the
headache.
B. Check the client's bladder for distension or
catheter occlusion.
C. Lower the head of the bed to a flat position.
D. Request an immediate stat CT scan of the head.
Answer: B
Rationale: These symptoms indicate autonomic
dysreflexia, a life-threatening emergency in
spinal cord injuries at or above T6. The most
common trigger is bladder distension. The nurse
must raise the head of the bed to 45 degrees or
higher and immediately remove the noxious
stimulus (e.g., empty the bladder or check for
fecal impaction).
Q6. A client is admitted with suspected bacterial
meningitis. Which diagnostic test must be
performed to definitively confirm the diagnosis,
and what nursing action is required prior to it?
NURSING II COMPREHENSIVE FINAL
REVIEW 100% CORRECT QUESTION
MASTER TEST PREP
Master your advanced nursing curriculum with this comprehensive,
question practice exam meticulously tailored for the Galen College
NU 185 Medical-Surgical Nursing II course. Each high-yield
question features italicized correct answers and detailed bold-
italicized rationales covering critical topics like neurology,
advanced burn management, endocrine emergencies, ECG
interpretation, and complex acid-base balance. Designed as the
ultimate academic assessment tool, this resource guarantees
100% correct, expert-verified rationales to help you ace your
exams and secure top grades.
Unit 1: Advanced Neurological Nursing
(Questions 1–13)
Q1. A nurse is assessing a client who was
admitted with a severe traumatic brain injury.
Which clinical manifestation should the nurse
recognize as the earliest indicator of increased
intracranial pressure (ICP)?
A. Widening pulse pressure
B. Ipsilateral pupillary dilation
C. Change in the level of consciousness (LOC)
D. Decerebrate posturing
Answer: C
,Rationale: A change in the level of
consciousness (such as agitation, lethargy, or
confusion) is the most sensitive and earliest
indicator of deteriorating neurological status and
increasing ICP. Changes in vital signs (Cushing’s
triad) and abnormal posturing are late signs.
Q2. A client with a history of tonic-clonic seizures
is admitted to the medical-surgical unit. Which
nursing intervention is a priority during an active
seizure event?
A. Insert an oral airway to prevent tongue biting.
B. Turn the client onto their side to maintain airway
patency.
C. Restrain the client's extremities to prevent
fractures.
D. Administer oral phenytoin immediately.
Answer: B
Rationale: Turning the client onto their side is
essential to allow saliva or emesis to drain,
keeping the airway clear and preventing
aspiration. Objects should never be placed in the
mouth, and the client should never be restrained.
Q3. The nurse is caring for a client with a history
of epilepsy who suddenly stops taking their
prescribed levetiracetam. What life-threatening
complication is this client at highest risk for
,developing?
A. Autonomic dysreflexia
B. Myasthenic crisis
C. Status epilepticus
D. Ischemic stroke
Answer: C
Rationale: Abruptly discontinuing or omitting
antiepileptic medications drops the therapeutic
drug level precipitously, which can trigger status
epilepticus—a continuous state of seizure
activity lasting more than 5 minutes that
constitutes a medical emergency.
Q4. A client who experienced an ischemic stroke
3 hours ago is being evaluated for intravenous
tissue plasminogen activator (tPA) therapy.
Which assessment finding serves as an absolute
contraindication for tPA?
A. Total symptom duration of 3 hours
B. Blood pressure reading of 140/90 mm Hg
C. Platelet count of 220,000/mm³
D. History of an intracranial hemorrhage
Answer: D
Rationale: A previous history of intracranial
hemorrhage, active internal bleeding, recent
intracranial surgery, or severe uncontrolled
hypertension are absolute contraindications for
, tPA due to the catastrophic risk of systemic or
cerebral bleeding.
Q5. A nurse is caring for a client with a T4 spinal
cord injury. The client suddenly reports a severe,
pounding headache and has a blood pressure of
190/100 mm Hg. What is the priority nursing
action?
A. Administer an ordered PRN analgesic for the
headache.
B. Check the client's bladder for distension or
catheter occlusion.
C. Lower the head of the bed to a flat position.
D. Request an immediate stat CT scan of the head.
Answer: B
Rationale: These symptoms indicate autonomic
dysreflexia, a life-threatening emergency in
spinal cord injuries at or above T6. The most
common trigger is bladder distension. The nurse
must raise the head of the bed to 45 degrees or
higher and immediately remove the noxious
stimulus (e.g., empty the bladder or check for
fecal impaction).
Q6. A client is admitted with suspected bacterial
meningitis. Which diagnostic test must be
performed to definitively confirm the diagnosis,
and what nursing action is required prior to it?
