NUR 265 MEDICAL-SURGICAL NURSING I EXAM 4 2026/2027
| Galen College Complete Solutions | 100% Correct Answers
with Detailed Rationales | GRADED A | Pass Guaranteed
Unit 1: Neurological Disorders (25 Questions)
Q1
Clinical Scenario: A 68-year-old male is admitted with a suspected ischemic stroke. His
vital signs are: BP 178/92, HR 88 (regular), RR 16, SpO2 94% on room air, temperature
37.1°C (98.8°F). He is alert and oriented to person and place but not time. His right arm
and leg show weakness (3/5 strength), and his speech is slightly slurred. The provider
orders a CT scan without contrast.
Which nursing action is the priority before the CT scan?
A. Administer tissue plasminogen activator (tPA) immediately to preserve brain tissue
B. Establish IV access and obtain baseline laboratory values including coagulation
studies
C. Position the patient flat with legs elevated to increase cerebral perfusion
D. Insert a nasogastric tube for enteral feeding to prevent aspiration
,Correct Answer: B [CORRECT]
Rationale: The priority before CT scan is establishing IV access and obtaining baseline
labs, particularly coagulation studies. This is essential because: (1) The CT must rule
out hemorrhagic stroke before any anticoagulant or thrombolytic therapy; (2)
Coagulation studies (PT/INR, aPTT, platelet count) are required to determine eligibility
for thrombolytic therapy if ischemic stroke is confirmed; (3) IV access is necessary for
contrast administration if needed and for emergency medication administration. The
patient's presentation (slurred speech, unilateral weakness, altered orientation) is
consistent with acute ischemic stroke, and time-critical protocols require rapid
assessment and preparation.
Distractor Analysis:
● A (Administer tPA immediately) is incorrect and dangerous because tPA is
contraindicated until hemorrhagic stroke is ruled out by CT. Administering tPA in
hemorrhagic stroke would cause catastrophic bleeding.
● C (Flat position with legs elevated) is incorrect because this position increases
cerebral blood volume and could worsen intracranial pressure if edema develops;
the head of bed should typically be elevated 30 degrees to promote venous
drainage.
● D (NG tube insertion) is incorrect because there is no indication for immediate
enteral feeding; the patient is alert enough to protect his airway, and NGT
insertion is not a priority over diagnostic workup and potential thrombolytic
eligibility assessment.
Galen NUR 265 Alignment: Neurological assessment priorities, stroke protocol,
thrombolytic therapy contraindications.
,Q2
Clinical Scenario: A 22-year-old female is admitted following a motor vehicle accident
with a closed head injury. Her Glasgow Coma Scale (GCS) score is calculated as: Eye
opening 2 (to pain), Verbal response 3 (inappropriate words), Motor response 4
(withdraws from pain).
What is the patient's GCS score, and what does this indicate?
A. GCS 9 indicating moderate traumatic brain injury with need for frequent neurological
assessments
B. GCS 8 indicating severe traumatic brain injury requiring immediate intubation
C. GCS 10 indicating minor head injury with routine monitoring
D. GCS 7 indicating coma with poor prognosis
Correct Answer: A [CORRECT]
Rationale: The GCS is calculated by summing the highest response in each category:
Eye (2) + Verbal (3) + Motor (4) = GCS 9. A GCS of 9-12 indicates moderate traumatic
brain injury (TBI). This requires: (1) Frequent neurological assessments (typically q1-2h);
(2) Close monitoring for signs of deterioration that would indicate increased intracranial
pressure (ICP); (3) Preparation for potential escalation if GCS declines to ≤8 (severe
TBI). The patient withdraws from pain (motor 4) rather than localizing (motor 5),
indicating significant neurological impairment but preserved brainstem function.
, Distractor Analysis:
● B (GCS 8, severe TBI) is incorrect because the calculation is wrong (2+3+4=9, not
8) and intubation is typically recommended for GCS ≤8, not 9, though airway
protection must be monitored.
● C (GCS 10, minor injury) is incorrect because the math is wrong and GCS 13-15
indicates minor head injury; this patient has moderate TBI.
● D (GCS 7, coma) is incorrect because the calculation is wrong and GCS 9 does
not indicate coma (typically GCS ≤8); prognosis cannot be determined from
single GCS score alone.
Galen NUR 265 Alignment: Glasgow Coma Scale calculation and interpretation, TBI
classification, neurological monitoring frequency.
Q3
Select All That Apply: A nurse is caring for a patient with increased intracranial pressure
(ICP) following a traumatic brain injury. Which nursing interventions are appropriate for
managing ICP? (Select all that apply)
A. Maintain head of bed elevation at 30 degrees
B. Suction the airway aggressively every 2 hours to prevent pneumonia
C. Administer mannitol 0.25-0.5 g/kg IV as ordered for increased ICP
D. Cluster nursing activities to allow extended rest periods
| Galen College Complete Solutions | 100% Correct Answers
with Detailed Rationales | GRADED A | Pass Guaranteed
Unit 1: Neurological Disorders (25 Questions)
Q1
Clinical Scenario: A 68-year-old male is admitted with a suspected ischemic stroke. His
vital signs are: BP 178/92, HR 88 (regular), RR 16, SpO2 94% on room air, temperature
37.1°C (98.8°F). He is alert and oriented to person and place but not time. His right arm
and leg show weakness (3/5 strength), and his speech is slightly slurred. The provider
orders a CT scan without contrast.
Which nursing action is the priority before the CT scan?
A. Administer tissue plasminogen activator (tPA) immediately to preserve brain tissue
B. Establish IV access and obtain baseline laboratory values including coagulation
studies
C. Position the patient flat with legs elevated to increase cerebral perfusion
D. Insert a nasogastric tube for enteral feeding to prevent aspiration
,Correct Answer: B [CORRECT]
Rationale: The priority before CT scan is establishing IV access and obtaining baseline
labs, particularly coagulation studies. This is essential because: (1) The CT must rule
out hemorrhagic stroke before any anticoagulant or thrombolytic therapy; (2)
Coagulation studies (PT/INR, aPTT, platelet count) are required to determine eligibility
for thrombolytic therapy if ischemic stroke is confirmed; (3) IV access is necessary for
contrast administration if needed and for emergency medication administration. The
patient's presentation (slurred speech, unilateral weakness, altered orientation) is
consistent with acute ischemic stroke, and time-critical protocols require rapid
assessment and preparation.
Distractor Analysis:
● A (Administer tPA immediately) is incorrect and dangerous because tPA is
contraindicated until hemorrhagic stroke is ruled out by CT. Administering tPA in
hemorrhagic stroke would cause catastrophic bleeding.
● C (Flat position with legs elevated) is incorrect because this position increases
cerebral blood volume and could worsen intracranial pressure if edema develops;
the head of bed should typically be elevated 30 degrees to promote venous
drainage.
● D (NG tube insertion) is incorrect because there is no indication for immediate
enteral feeding; the patient is alert enough to protect his airway, and NGT
insertion is not a priority over diagnostic workup and potential thrombolytic
eligibility assessment.
Galen NUR 265 Alignment: Neurological assessment priorities, stroke protocol,
thrombolytic therapy contraindications.
,Q2
Clinical Scenario: A 22-year-old female is admitted following a motor vehicle accident
with a closed head injury. Her Glasgow Coma Scale (GCS) score is calculated as: Eye
opening 2 (to pain), Verbal response 3 (inappropriate words), Motor response 4
(withdraws from pain).
What is the patient's GCS score, and what does this indicate?
A. GCS 9 indicating moderate traumatic brain injury with need for frequent neurological
assessments
B. GCS 8 indicating severe traumatic brain injury requiring immediate intubation
C. GCS 10 indicating minor head injury with routine monitoring
D. GCS 7 indicating coma with poor prognosis
Correct Answer: A [CORRECT]
Rationale: The GCS is calculated by summing the highest response in each category:
Eye (2) + Verbal (3) + Motor (4) = GCS 9. A GCS of 9-12 indicates moderate traumatic
brain injury (TBI). This requires: (1) Frequent neurological assessments (typically q1-2h);
(2) Close monitoring for signs of deterioration that would indicate increased intracranial
pressure (ICP); (3) Preparation for potential escalation if GCS declines to ≤8 (severe
TBI). The patient withdraws from pain (motor 4) rather than localizing (motor 5),
indicating significant neurological impairment but preserved brainstem function.
, Distractor Analysis:
● B (GCS 8, severe TBI) is incorrect because the calculation is wrong (2+3+4=9, not
8) and intubation is typically recommended for GCS ≤8, not 9, though airway
protection must be monitored.
● C (GCS 10, minor injury) is incorrect because the math is wrong and GCS 13-15
indicates minor head injury; this patient has moderate TBI.
● D (GCS 7, coma) is incorrect because the calculation is wrong and GCS 9 does
not indicate coma (typically GCS ≤8); prognosis cannot be determined from
single GCS score alone.
Galen NUR 265 Alignment: Glasgow Coma Scale calculation and interpretation, TBI
classification, neurological monitoring frequency.
Q3
Select All That Apply: A nurse is caring for a patient with increased intracranial pressure
(ICP) following a traumatic brain injury. Which nursing interventions are appropriate for
managing ICP? (Select all that apply)
A. Maintain head of bed elevation at 30 degrees
B. Suction the airway aggressively every 2 hours to prevent pneumonia
C. Administer mannitol 0.25-0.5 g/kg IV as ordered for increased ICP
D. Cluster nursing activities to allow extended rest periods
