Exam 4: NUR 201 Medical-Surgical Nursing I
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Integrated Content Focus: Neurological System, Gastrointestinal System &
Nutritional Support Frameworks
Q1: A 19-year-old patient with a known seizure disorder is admitted after having two tonic-
clonic seizures in 30 minutes without regaining consciousness between episodes. Which
condition is present?
A. Simple partial status epilepticus
B. Generalized convulsive status epilepticus
C. Absence seizure cluster
D. Complex partial seizure with secondary generalization
Correct Answer: B
Rationale: Correct because generalized convulsive status epilepticus is defined as continuous
seizure activity lasting longer than 5 minutes or recurrent seizures without recovery of
consciousness between episodes, which is exactly what this patient is experiencing. This is a
neurological emergency requiring immediate IV benzodiazepine administration (lorazepam or
diazepam) followed by loading doses of antiepileptic medications. Prolonged seizure activity
causes neuronal hypoxia, acidosis, rhabdomyolysis, hyperthermia, and death if not terminated
promptly. The nurse must maintain airway patency, administer oxygen, protect from injury, and
prepare for possible intubation if airway compromise develops.
,Q2: A patient with a severe head injury has a Glasgow Coma Scale score of 7. The provider
orders a lumbar puncture to rule out meningitis. Which nursing action is most appropriate?
A. Prepare the patient and assist with the lumbar puncture
B. Notify the provider that the procedure is contraindicated
C. Administer sedation to facilitate patient cooperation
D. Position the patient in lateral recumbent position
Correct Answer: D
Rationale: Correct because lumbar puncture is absolutely contraindicated in patients with altered
mental status and suspected increased intracranial pressure from head trauma, as removing
cerebrospinal fluid from the spinal column creates a pressure gradient that can cause fatal brain
herniation through the foramen magnum. A GCS score of 7 indicates severe neurological
impairment. The nurse must question the order, notify the provider of the contraindication, and
advocate for head CT imaging as the safer diagnostic alternative. Signs of increased ICP include
headache, vomiting, pupillary changes, and Cushing's triad. The nurse should never proceed with
a contraindicated procedure even when ordered.
Q3: A patient with a T6 spinal cord injury is sitting in a wheelchair during physical therapy and
suddenly develops a severe pounding headache. The therapist notes profuse sweating above the
nipple line and goosebumps below. Blood pressure is 260/140 mmHg. Which condition should
the nurse suspect?
A. Neurogenic shock from spinal cord injury
B. Autonomic dysreflexia
C. Malignant hypertension from renal failure
D. Pheochromocytoma
Correct Answer: A
Rationale: Correct because autonomic dysreflexia is a life-threatening hypertensive emergency
in patients with spinal cord injuries at or above T6, characterized by severe hypertension (often
>200/100 mmHg), throbbing headache, bradycardia or reflex tachycardia, intense sweating and
flushing above the level of injury, and pale cold skin with piloerection (goosebumps) below the
level of injury. The massive sympathetic discharge is triggered by a noxious stimulus below the
injury level, most commonly bladder distention. The priority interventions are to sit the patient
upright immediately, identify and eliminate the trigger, and notify the provider for
antihypertensive orders. If untreated, this can cause stroke, myocardial infarction, seizures, and
death.
, Q4: A patient with a right hemisphere stroke has left-sided homonymous hemianopsia. The nurse
is setting up the patient's room after transfer from ICU. Which action is most appropriate?
A. Place the call light, water pitcher, and personal items on the left side
B. Position all essential items on the patient's right side
C. Arrange furniture symmetrically to encourage visual scanning
D. Place a brightly colored marker on the left side of the doorway
Correct Answer: C
Rationale: Correct because patients with left homonymous hemianopsia have lost the left visual
field in both eyes and cannot see items placed on the left side, so the nurse must place essential
items including the call light, water pitcher, personal belongings, and bed controls on the
patient's unaffected (right) side to ensure the patient can locate and use them independently.
Placing items on the affected side is ineffective; symmetrical furniture arrangement does not
address the visual deficit; and doorway markers on the affected side are not processed by the
patient. The nurse should also teach the patient to consciously scan to the left and turn the head
to compensate.
Q5: A patient with acute pancreatitis reports severe, constant upper abdominal pain that radiates
through to the back and is partially relieved by sitting forward. The nurse notes bluish
discoloration of the flanks. Which sign is present?
A. Cullen's sign
B. Grey Turner's sign
C. Kehr's sign
D. Murphy's sign
Correct Answer: D
Rationale: Correct because Grey Turner's sign (also called Turner's sign) is bluish discoloration
of the flanks indicating retroperitoneal hemorrhage, which is a hallmark of severe hemorrhagic
pancreatitis caused by retroperitoneal bleeding tracking through tissue planes to the
subcutaneous tissues of the flanks. Cullen's sign is bluish discoloration around the umbilicus
indicating intraperitoneal hemorrhage; Kehr's sign is left shoulder pain indicating splenic injury
or hemoperitoneum; and Murphy's sign is inspiratory arrest with right upper quadrant palpation
indicating cholecystitis. The priority interventions for acute pancreatitis include strict NPO
status, NG tube decompression, aggressive IV fluid hydration, and IV pain management.
2026/2027 |Newly Released| Fortis College
50 Questions & Answers |Grade A+
100% Correct Rationales | Complete Guide
Guaranteed Pass
Integrated Content Focus: Neurological System, Gastrointestinal System &
Nutritional Support Frameworks
Q1: A 19-year-old patient with a known seizure disorder is admitted after having two tonic-
clonic seizures in 30 minutes without regaining consciousness between episodes. Which
condition is present?
A. Simple partial status epilepticus
B. Generalized convulsive status epilepticus
C. Absence seizure cluster
D. Complex partial seizure with secondary generalization
Correct Answer: B
Rationale: Correct because generalized convulsive status epilepticus is defined as continuous
seizure activity lasting longer than 5 minutes or recurrent seizures without recovery of
consciousness between episodes, which is exactly what this patient is experiencing. This is a
neurological emergency requiring immediate IV benzodiazepine administration (lorazepam or
diazepam) followed by loading doses of antiepileptic medications. Prolonged seizure activity
causes neuronal hypoxia, acidosis, rhabdomyolysis, hyperthermia, and death if not terminated
promptly. The nurse must maintain airway patency, administer oxygen, protect from injury, and
prepare for possible intubation if airway compromise develops.
,Q2: A patient with a severe head injury has a Glasgow Coma Scale score of 7. The provider
orders a lumbar puncture to rule out meningitis. Which nursing action is most appropriate?
A. Prepare the patient and assist with the lumbar puncture
B. Notify the provider that the procedure is contraindicated
C. Administer sedation to facilitate patient cooperation
D. Position the patient in lateral recumbent position
Correct Answer: D
Rationale: Correct because lumbar puncture is absolutely contraindicated in patients with altered
mental status and suspected increased intracranial pressure from head trauma, as removing
cerebrospinal fluid from the spinal column creates a pressure gradient that can cause fatal brain
herniation through the foramen magnum. A GCS score of 7 indicates severe neurological
impairment. The nurse must question the order, notify the provider of the contraindication, and
advocate for head CT imaging as the safer diagnostic alternative. Signs of increased ICP include
headache, vomiting, pupillary changes, and Cushing's triad. The nurse should never proceed with
a contraindicated procedure even when ordered.
Q3: A patient with a T6 spinal cord injury is sitting in a wheelchair during physical therapy and
suddenly develops a severe pounding headache. The therapist notes profuse sweating above the
nipple line and goosebumps below. Blood pressure is 260/140 mmHg. Which condition should
the nurse suspect?
A. Neurogenic shock from spinal cord injury
B. Autonomic dysreflexia
C. Malignant hypertension from renal failure
D. Pheochromocytoma
Correct Answer: A
Rationale: Correct because autonomic dysreflexia is a life-threatening hypertensive emergency
in patients with spinal cord injuries at or above T6, characterized by severe hypertension (often
>200/100 mmHg), throbbing headache, bradycardia or reflex tachycardia, intense sweating and
flushing above the level of injury, and pale cold skin with piloerection (goosebumps) below the
level of injury. The massive sympathetic discharge is triggered by a noxious stimulus below the
injury level, most commonly bladder distention. The priority interventions are to sit the patient
upright immediately, identify and eliminate the trigger, and notify the provider for
antihypertensive orders. If untreated, this can cause stroke, myocardial infarction, seizures, and
death.
, Q4: A patient with a right hemisphere stroke has left-sided homonymous hemianopsia. The nurse
is setting up the patient's room after transfer from ICU. Which action is most appropriate?
A. Place the call light, water pitcher, and personal items on the left side
B. Position all essential items on the patient's right side
C. Arrange furniture symmetrically to encourage visual scanning
D. Place a brightly colored marker on the left side of the doorway
Correct Answer: C
Rationale: Correct because patients with left homonymous hemianopsia have lost the left visual
field in both eyes and cannot see items placed on the left side, so the nurse must place essential
items including the call light, water pitcher, personal belongings, and bed controls on the
patient's unaffected (right) side to ensure the patient can locate and use them independently.
Placing items on the affected side is ineffective; symmetrical furniture arrangement does not
address the visual deficit; and doorway markers on the affected side are not processed by the
patient. The nurse should also teach the patient to consciously scan to the left and turn the head
to compensate.
Q5: A patient with acute pancreatitis reports severe, constant upper abdominal pain that radiates
through to the back and is partially relieved by sitting forward. The nurse notes bluish
discoloration of the flanks. Which sign is present?
A. Cullen's sign
B. Grey Turner's sign
C. Kehr's sign
D. Murphy's sign
Correct Answer: D
Rationale: Correct because Grey Turner's sign (also called Turner's sign) is bluish discoloration
of the flanks indicating retroperitoneal hemorrhage, which is a hallmark of severe hemorrhagic
pancreatitis caused by retroperitoneal bleeding tracking through tissue planes to the
subcutaneous tissues of the flanks. Cullen's sign is bluish discoloration around the umbilicus
indicating intraperitoneal hemorrhage; Kehr's sign is left shoulder pain indicating splenic injury
or hemoperitoneum; and Murphy's sign is inspiratory arrest with right upper quadrant palpation
indicating cholecystitis. The priority interventions for acute pancreatitis include strict NPO
status, NG tube decompression, aggressive IV fluid hydration, and IV pain management.
