Advanced Med Surg 2025 | Advanced Med Surg Exam Questions and Correct
Answers, latest (Best for Exam Practice) | Graded A+
1. The nurse is working in the emergency department (ED) is admitting a client who has sustained a
traumatic brain injury (TBI) following a motor vehicle crash. It is priority for the nurse to notify the
primary healthcare provider (PHCP) in the client.
a) Reports having a continuous headache.
b) Has a blood pressure of 162/94 mm Hg.
c) Is unable to remember the crash.
d) Takes prescribed warfarin daily. *
RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment of
impact. Warfarin is a blood thinner and the patient may bleed out if they have a hematoma (a collection of
blood)
2. The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury,
is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following actions, if
performed by the newly hired nurse, requires intervention by the charge nurse?
a) Using the bag-valve mask on the client when the low-pressure alarm sounds.
b) Raising the foot of the client’s bed. *
c) Setting up suction equipment at bedside.
d) Maintaining the client’s head at midline, neutral position.
RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP.
3. The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk
for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed
a) Instructing the client not to assist during positioning.
b) Checking the client’s VS every hour.
c) Clustering client care activities. *
d) Encouraging the client’s visitors not to stimulate the client.
RATIONALE: pg. 2387. When multiple activities are clustered in a row, the effect on ICP can be dramatic
elevation.
4. The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should
the nurse identify as being at greatest risk?
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, a) 45-year-old who has epilepsy and takes prescribed phenytoin.
b) 20-year-old college student who participates on the football team. *
c) 7-year-old who is learning how to ride a bicycle without training wheels.
d) 60-year-old who lives alone and wears a hearing aid.
RATIONALE: Pg. 2397. A force produce by a blow direct to the head can contribute to a brain injury.
5. The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse
to notify the PHCP?
a) An output of 30 mL from the surgical drain of a client who had a craniotomy 6 hours ago.
b) A decrease in the Glasgow coma scale (GCS) score from 4 to 3 in a client who has a brain tumor.
c) A report of tinnitus by a client who was recently diagnosed with an acoustic neuroma.
d) The development of asymmetric pupils with no reaction to light in a client who has a TBI. *
RATIONALE: Pg. 2386. Pupillary changes; dilated and non reactive pupils “blown” or constrictive, non
reactive pupils.
6. The nurse is caring for a client who had a TBI with skull fracture. The nurse noted that the client has
developed rhinorrhea (nasal drip) that is positive for glucose. Which of the following actions should the
nurse take next?
a) Apply a drip pad to the client’s nose.
b) Perform a halo sign test. *
c) Prepare to suction the client.
d) Notify the PHCP.
RATIONALE: Pg. 2410. CSF leaking, lab test will be analyzed for glucose and electrolyte content. Place
on a white absorbent paper or linen.
7. The nurse is assessing a client who has experienced a mild TBI. Which of the following findings is
consistent with this diagnosis?
a. Difficulty concentrating*
b. A Glasgow coma scale score of 11
c. Constricted pupils that are nonreactive to light
d. Hand tremors
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, 8. The nurse is providing discharge instructions to the partner of a client who sustained a mild head
injury as a result of a motor vehicle crash. Which of the following statements, if made by a partner,
would indicate the need for additional teaching?
a) “It is possible that my partner may experience nausea for at least 24 hours”.
b) “I will bring my partner to the ED immediately if they begin to vomit”.*
c) “If my partner is sleeping, I will wake them up every 5-6 hours”.
d) “I will monitor my partner when ambulating or moving around”.
RATIONALE: Pg. 2405. Symptoms usually resolve within 72 hrs. NV expected.
Then nurse is providing discharge instructions to the partner of a client who sustained a mild head injury
as a result of a motor vehicle crash. Which of the following statements by a partner indicates a correct
understanding of the teaching?
a. I will bring my partner to the ED immediately if they begin to vomit
b. It is expected that my partner will have drainage from the nose for the next few days
c. If my partner is sleeping I will wake them up every 5-6 hours*
d. I will give my partner a lorazepam tonight to help with anxiety
The nurse is caring for the following assigned clients. Which client should the nurse see first?
a. The client who has a skull fracture, is alert and oriented, and reports feeling nauseated
b. The client who has meningitis, is irritable, and reporting a HA*
c. The client who has encephalitis and development of myoclonic jerking and tremors
d. The client who has a brain injury and unable to remember the events surrounding the injury
9. The nurse is caring for the following assigned clients. Which client should the nurse see first?
a) The client who has meningitis, is irritable and reporting a headache.
b) The client who has encephalitis and is reporting sensitivity to light and noise.
c) The client who has a brain injury and a BP change from 110/58 to 134/40 mm Hg. *
d) The client who has a skull fracture, is alert and oriented and reports feeling nauseated.
RATIONALE: Pg. 2386. Cushing Triad. Severe HTN, widened pulse pressure, bradycardia.
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Answers, latest (Best for Exam Practice) | Graded A+
1. The nurse is working in the emergency department (ED) is admitting a client who has sustained a
traumatic brain injury (TBI) following a motor vehicle crash. It is priority for the nurse to notify the
primary healthcare provider (PHCP) in the client.
a) Reports having a continuous headache.
b) Has a blood pressure of 162/94 mm Hg.
c) Is unable to remember the crash.
d) Takes prescribed warfarin daily. *
RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment of
impact. Warfarin is a blood thinner and the patient may bleed out if they have a hematoma (a collection of
blood)
2. The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury,
is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following actions, if
performed by the newly hired nurse, requires intervention by the charge nurse?
a) Using the bag-valve mask on the client when the low-pressure alarm sounds.
b) Raising the foot of the client’s bed. *
c) Setting up suction equipment at bedside.
d) Maintaining the client’s head at midline, neutral position.
RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP.
3. The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk
for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed
a) Instructing the client not to assist during positioning.
b) Checking the client’s VS every hour.
c) Clustering client care activities. *
d) Encouraging the client’s visitors not to stimulate the client.
RATIONALE: pg. 2387. When multiple activities are clustered in a row, the effect on ICP can be dramatic
elevation.
4. The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should
the nurse identify as being at greatest risk?
1|Page
, a) 45-year-old who has epilepsy and takes prescribed phenytoin.
b) 20-year-old college student who participates on the football team. *
c) 7-year-old who is learning how to ride a bicycle without training wheels.
d) 60-year-old who lives alone and wears a hearing aid.
RATIONALE: Pg. 2397. A force produce by a blow direct to the head can contribute to a brain injury.
5. The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse
to notify the PHCP?
a) An output of 30 mL from the surgical drain of a client who had a craniotomy 6 hours ago.
b) A decrease in the Glasgow coma scale (GCS) score from 4 to 3 in a client who has a brain tumor.
c) A report of tinnitus by a client who was recently diagnosed with an acoustic neuroma.
d) The development of asymmetric pupils with no reaction to light in a client who has a TBI. *
RATIONALE: Pg. 2386. Pupillary changes; dilated and non reactive pupils “blown” or constrictive, non
reactive pupils.
6. The nurse is caring for a client who had a TBI with skull fracture. The nurse noted that the client has
developed rhinorrhea (nasal drip) that is positive for glucose. Which of the following actions should the
nurse take next?
a) Apply a drip pad to the client’s nose.
b) Perform a halo sign test. *
c) Prepare to suction the client.
d) Notify the PHCP.
RATIONALE: Pg. 2410. CSF leaking, lab test will be analyzed for glucose and electrolyte content. Place
on a white absorbent paper or linen.
7. The nurse is assessing a client who has experienced a mild TBI. Which of the following findings is
consistent with this diagnosis?
a. Difficulty concentrating*
b. A Glasgow coma scale score of 11
c. Constricted pupils that are nonreactive to light
d. Hand tremors
2|Page
, 8. The nurse is providing discharge instructions to the partner of a client who sustained a mild head
injury as a result of a motor vehicle crash. Which of the following statements, if made by a partner,
would indicate the need for additional teaching?
a) “It is possible that my partner may experience nausea for at least 24 hours”.
b) “I will bring my partner to the ED immediately if they begin to vomit”.*
c) “If my partner is sleeping, I will wake them up every 5-6 hours”.
d) “I will monitor my partner when ambulating or moving around”.
RATIONALE: Pg. 2405. Symptoms usually resolve within 72 hrs. NV expected.
Then nurse is providing discharge instructions to the partner of a client who sustained a mild head injury
as a result of a motor vehicle crash. Which of the following statements by a partner indicates a correct
understanding of the teaching?
a. I will bring my partner to the ED immediately if they begin to vomit
b. It is expected that my partner will have drainage from the nose for the next few days
c. If my partner is sleeping I will wake them up every 5-6 hours*
d. I will give my partner a lorazepam tonight to help with anxiety
The nurse is caring for the following assigned clients. Which client should the nurse see first?
a. The client who has a skull fracture, is alert and oriented, and reports feeling nauseated
b. The client who has meningitis, is irritable, and reporting a HA*
c. The client who has encephalitis and development of myoclonic jerking and tremors
d. The client who has a brain injury and unable to remember the events surrounding the injury
9. The nurse is caring for the following assigned clients. Which client should the nurse see first?
a) The client who has meningitis, is irritable and reporting a headache.
b) The client who has encephalitis and is reporting sensitivity to light and noise.
c) The client who has a brain injury and a BP change from 110/58 to 134/40 mm Hg. *
d) The client who has a skull fracture, is alert and oriented and reports feeling nauseated.
RATIONALE: Pg. 2386. Cushing Triad. Severe HTN, widened pulse pressure, bradycardia.
3|Page
