,NUR201 Medical-Surgical Nursing I Exam 4
Study Guide & 150 Practice Questions Fortis
College 2026/2027
1. A 72-year-old patient is admitted with sudden onset of left-sided weakness and slurred
speech that began 45 minutes ago. The nurse notes facial drooping on the left side and a
National Institutes of Health Stroke Scale (NIHSS) score of 12. A non-contrast CT scan of the
head is negative for hemorrhage. Which action should the nurse anticipate as the priority
intervention?
A. Administer aspirin 325 mg orally to prevent further clot formation.
B. Prepare the patient for intravenous alteplase (tPA) therapy.
C. Place the patient in a supine position with the head flat.
D. Initiate supplemental oxygen at 4 L/min via nasal cannula.
Correct Answer: B. Prepare the patient for intravenous alteplase (tPA) therapy.
Rationale: For an acute ischemic stroke with symptom onset within 3 to 4.5 hours, IV alteplase
is the priority intervention to restore cerebral blood flow and minimize permanent neurological
damage. The CT scan must first rule out hemorrhage before thrombolytic therapy can be
administered. Aspirin is not given within 24 hours of tPA.
,2. A nurse is caring for a patient who experienced a hemorrhagic stroke. Which assessment
finding requires immediate notification of the healthcare provider?
A. Blood pressure of 150/90 mm Hg.
B. Heart rate of 88 beats/min.
C. New onset of severe headache with vomiting.
D. Glasgow Coma Scale score of 14.
Correct Answer: C. New onset of severe headache with vomiting.
Rationale: In a patient with a hemorrhagic stroke, a sudden severe headache with vomiting may
indicate rebleeding or increased intracranial pressure, which requires immediate intervention. A
GCS of 14 indicates mild impairment and is not the priority concern. Blood pressure
management is important but not the most urgent finding.
3. A nurse is assessing a patient with a head injury. Which finding indicates a possible basilar
skull fracture?
A. Periorbital ecchymosis (raccoon eyes).
B. Bruising behind the ears (Battle's sign).
C. Clear drainage from the nose (CSF rhinorrhea).
, D. All of the above.
Correct Answer: D. All of the above.
Rationale: Raccoon eyes (periorbital ecchymosis), Battle's sign (bruising behind the ears), and
CSF rhinorrhea or otorrhea are classic signs of a basilar skull fracture. Any of these findings
should be reported to the healthcare provider immediately.
4. A nurse is teaching a patient about seizure precautions. Which instruction should the nurse
include?
A. "You should place a tongue blade in your mouth if you feel a seizure coming on."
B. "You should take your antiseizure medication at the same time every day."
C. "You should stop taking your medication if you have been seizure-free for 6 months."
D. "You should avoid all physical activity to prevent seizures."
Correct Answer: B. "You should take your antiseizure medication at the same time every day."
Rationale: Antiseizure medications must be taken consistently at the same time every day to
maintain therapeutic blood levels and prevent seizures. Patients should never place anything in
their mouth during a seizure or stop medication without consulting their provider. Physical
activity is generally safe and beneficial.
Study Guide & 150 Practice Questions Fortis
College 2026/2027
1. A 72-year-old patient is admitted with sudden onset of left-sided weakness and slurred
speech that began 45 minutes ago. The nurse notes facial drooping on the left side and a
National Institutes of Health Stroke Scale (NIHSS) score of 12. A non-contrast CT scan of the
head is negative for hemorrhage. Which action should the nurse anticipate as the priority
intervention?
A. Administer aspirin 325 mg orally to prevent further clot formation.
B. Prepare the patient for intravenous alteplase (tPA) therapy.
C. Place the patient in a supine position with the head flat.
D. Initiate supplemental oxygen at 4 L/min via nasal cannula.
Correct Answer: B. Prepare the patient for intravenous alteplase (tPA) therapy.
Rationale: For an acute ischemic stroke with symptom onset within 3 to 4.5 hours, IV alteplase
is the priority intervention to restore cerebral blood flow and minimize permanent neurological
damage. The CT scan must first rule out hemorrhage before thrombolytic therapy can be
administered. Aspirin is not given within 24 hours of tPA.
,2. A nurse is caring for a patient who experienced a hemorrhagic stroke. Which assessment
finding requires immediate notification of the healthcare provider?
A. Blood pressure of 150/90 mm Hg.
B. Heart rate of 88 beats/min.
C. New onset of severe headache with vomiting.
D. Glasgow Coma Scale score of 14.
Correct Answer: C. New onset of severe headache with vomiting.
Rationale: In a patient with a hemorrhagic stroke, a sudden severe headache with vomiting may
indicate rebleeding or increased intracranial pressure, which requires immediate intervention. A
GCS of 14 indicates mild impairment and is not the priority concern. Blood pressure
management is important but not the most urgent finding.
3. A nurse is assessing a patient with a head injury. Which finding indicates a possible basilar
skull fracture?
A. Periorbital ecchymosis (raccoon eyes).
B. Bruising behind the ears (Battle's sign).
C. Clear drainage from the nose (CSF rhinorrhea).
, D. All of the above.
Correct Answer: D. All of the above.
Rationale: Raccoon eyes (periorbital ecchymosis), Battle's sign (bruising behind the ears), and
CSF rhinorrhea or otorrhea are classic signs of a basilar skull fracture. Any of these findings
should be reported to the healthcare provider immediately.
4. A nurse is teaching a patient about seizure precautions. Which instruction should the nurse
include?
A. "You should place a tongue blade in your mouth if you feel a seizure coming on."
B. "You should take your antiseizure medication at the same time every day."
C. "You should stop taking your medication if you have been seizure-free for 6 months."
D. "You should avoid all physical activity to prevent seizures."
Correct Answer: B. "You should take your antiseizure medication at the same time every day."
Rationale: Antiseizure medications must be taken consistently at the same time every day to
maintain therapeutic blood levels and prevent seizures. Patients should never place anything in
their mouth during a seizure or stop medication without consulting their provider. Physical
activity is generally safe and beneficial.
