MEDICAL-SURGICAL NURSING 1 – FINAL
EXAM STUDY GUIDE – COMPREHENSIVE
Q&A AND RATIONALES | NURSING
PROGRAM | 2024 | COMPLETE EXAM
PREPARATION RESOURCE
[Document subtitle]
, Medical-Surgical Nursing 1 Final Exam:
Comprehensive Study Guide, Key Topics, and
Expert Solutions
1. A patient with a T6 injury reports a pounding headache, blurred vision, and nasal
congestion. The nursey observes profuse sweating above the level of injury. What is
the priority action by the nursey?
a. Irrigate the patient's indwelling catheter.
b. Elevate the patient's head.
c. Place the patient in Trendelenburg position.
d. Obtain the patient's temperature.
Rationale:
The patient is exhibiting signs of autonomic dysreflexia (AD), a life-threatening condition
that can occur in patients with spinal cord injuries at T6 or above. The priority action is to
elevate the head to help lower blood pressure and prevent complications such as stroke.
The nursey should then identify and eliminate the cause (e.g., bladder distension or fecal
impaction).
2. The nursey witnesses a patient having a tonic-clonic seizure in the bed. What is
the priority action by the nursey?
a. Insert a tongue blade between the patient's teeth.
b. Place the patient in the prone position.
c. Turn the head to the side.
d. Insert an indwelling catheter.
Rationale:
During a seizure, turning the head to the side helps maintain an open airway and prevents
aspiration of secretions or vomitus. Placing objects in the mouth (e.g., tongue blade) can
cause injury. The prone position may obstruct breathing.
1
,3. The nursey is reinforcing education for a female patient paralyzed from a spinal
cord injury (SCI). What statement made by the patient demonstrates understanding
of the education?
a. "I may begin to menstruate within 3 months following my injury."
b. "I should use birth control pills as a means of contraception."
c. "It is just as safe for me to become pregnant as a woman without an SCI."
d. "I should use a tampon instead of a feminine pad when I am menstruating."
Rationale:
Menstruation usually resumes within 3 months following a spinal cord injury. Women
with SCI can become pregnant but may require specialized care due to autonomic
dysreflexia risks during labor. Birth control pills may not be ideal due to increased risk of
blood clots. Tampons are not recommended due to decreased sensation and risk of toxic
shock syndrome.
4. The nursey is requested to place an ice pack on the eyelid for 2 minutes for a
patient suspected of having myasthenia gravis (MG) with diplopia. What outcome
does the nursey anticipate if the diagnosis is confirmed?
a. The patient will have an improvement in respiratory status.
b. The patient will have blindness.
c. The patient will have a grave prognosis.
d. The patient will have a temporary improvement in eye symptoms.
Rationale:
The ice test is used to diagnose myasthenia gravis (MG) by improving muscle weakness
temporarily. The cold temperature inhibits acetylcholine breakdown, allowing for short-
term improvement in ptosis and diplopia. It does not affect respiratory status or lead to
blindness.
5. A patient is diagnosed with arthritis and wants to maintain an active lifestyle.
What exercises should the nursey recommend to the patient? (Select all that
apply.)
a. Swimming
b. Jumping rope
c. Bicycling
2
, d. Running
e. Slow walking
Rationale:
Low-impact exercises such as swimming, bicycling, and slow walking help maintain
joint flexibility and reduce stiffness without causing excessive strain. High-impact
activities like jumping rope and running can worsen joint pain and inflammation.
6. A patient is experiencing residual limb pain following a surgical amputation to
the right lower extremity below the knee. What action by the nursey would help
alleviate the pain?
a. Have the patient "move" the missing limb.
b. Apply ice packs to the residual limb.
c. Have the patient discuss feelings of loss.
d. Present reality and do not support the delusion of sensation.
Rationale:
Phantom limb pain occurs when the brain continues to send signals to the amputated
limb. Encouraging the patient to "move" the missing limb (mirror therapy or mental
imagery) can help rewire the brain’s perception and reduce pain. Ice packs are ineffective
for phantom pain.
7.The nursey is caring for a patient who has had a lower extremity amputation.
What intervention by the nursey will best prevent hip contractures?
a. Change drains using aseptic technique.
b. Elevate the foot of the bed.
c. Inspect the limb for signs of infection.
d. Do not place a pillow under the residual limb. - - correct ans- -d. Do not place a pillow
under the residual limb.
3
EXAM STUDY GUIDE – COMPREHENSIVE
Q&A AND RATIONALES | NURSING
PROGRAM | 2024 | COMPLETE EXAM
PREPARATION RESOURCE
[Document subtitle]
, Medical-Surgical Nursing 1 Final Exam:
Comprehensive Study Guide, Key Topics, and
Expert Solutions
1. A patient with a T6 injury reports a pounding headache, blurred vision, and nasal
congestion. The nursey observes profuse sweating above the level of injury. What is
the priority action by the nursey?
a. Irrigate the patient's indwelling catheter.
b. Elevate the patient's head.
c. Place the patient in Trendelenburg position.
d. Obtain the patient's temperature.
Rationale:
The patient is exhibiting signs of autonomic dysreflexia (AD), a life-threatening condition
that can occur in patients with spinal cord injuries at T6 or above. The priority action is to
elevate the head to help lower blood pressure and prevent complications such as stroke.
The nursey should then identify and eliminate the cause (e.g., bladder distension or fecal
impaction).
2. The nursey witnesses a patient having a tonic-clonic seizure in the bed. What is
the priority action by the nursey?
a. Insert a tongue blade between the patient's teeth.
b. Place the patient in the prone position.
c. Turn the head to the side.
d. Insert an indwelling catheter.
Rationale:
During a seizure, turning the head to the side helps maintain an open airway and prevents
aspiration of secretions or vomitus. Placing objects in the mouth (e.g., tongue blade) can
cause injury. The prone position may obstruct breathing.
1
,3. The nursey is reinforcing education for a female patient paralyzed from a spinal
cord injury (SCI). What statement made by the patient demonstrates understanding
of the education?
a. "I may begin to menstruate within 3 months following my injury."
b. "I should use birth control pills as a means of contraception."
c. "It is just as safe for me to become pregnant as a woman without an SCI."
d. "I should use a tampon instead of a feminine pad when I am menstruating."
Rationale:
Menstruation usually resumes within 3 months following a spinal cord injury. Women
with SCI can become pregnant but may require specialized care due to autonomic
dysreflexia risks during labor. Birth control pills may not be ideal due to increased risk of
blood clots. Tampons are not recommended due to decreased sensation and risk of toxic
shock syndrome.
4. The nursey is requested to place an ice pack on the eyelid for 2 minutes for a
patient suspected of having myasthenia gravis (MG) with diplopia. What outcome
does the nursey anticipate if the diagnosis is confirmed?
a. The patient will have an improvement in respiratory status.
b. The patient will have blindness.
c. The patient will have a grave prognosis.
d. The patient will have a temporary improvement in eye symptoms.
Rationale:
The ice test is used to diagnose myasthenia gravis (MG) by improving muscle weakness
temporarily. The cold temperature inhibits acetylcholine breakdown, allowing for short-
term improvement in ptosis and diplopia. It does not affect respiratory status or lead to
blindness.
5. A patient is diagnosed with arthritis and wants to maintain an active lifestyle.
What exercises should the nursey recommend to the patient? (Select all that
apply.)
a. Swimming
b. Jumping rope
c. Bicycling
2
, d. Running
e. Slow walking
Rationale:
Low-impact exercises such as swimming, bicycling, and slow walking help maintain
joint flexibility and reduce stiffness without causing excessive strain. High-impact
activities like jumping rope and running can worsen joint pain and inflammation.
6. A patient is experiencing residual limb pain following a surgical amputation to
the right lower extremity below the knee. What action by the nursey would help
alleviate the pain?
a. Have the patient "move" the missing limb.
b. Apply ice packs to the residual limb.
c. Have the patient discuss feelings of loss.
d. Present reality and do not support the delusion of sensation.
Rationale:
Phantom limb pain occurs when the brain continues to send signals to the amputated
limb. Encouraging the patient to "move" the missing limb (mirror therapy or mental
imagery) can help rewire the brain’s perception and reduce pain. Ice packs are ineffective
for phantom pain.
7.The nursey is caring for a patient who has had a lower extremity amputation.
What intervention by the nursey will best prevent hip contractures?
a. Change drains using aseptic technique.
b. Elevate the foot of the bed.
c. Inspect the limb for signs of infection.
d. Do not place a pillow under the residual limb. - - correct ans- -d. Do not place a pillow
under the residual limb.
3
