Medsurg 2 Final Exam Summer 2025

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

• The client can follow simple motor commands.

• The client is unable to make vocal sound.

• The client is unconscious.

• The client opens his eyes when spoken to.

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

• The client requires total nursing care.

• The client is alert and oriented.

• The client is in a deep coma.

• The client has a stable neurological status.

A nurse is reinforcing teaching with a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client should the nurse identify as understanding of the teaching?

• I can take medication up to 2 hr before the procedure.

• I should not eat or drink anything for 4-6 hours before the procedure.

• I can drive myself home after the procedure.

• I will need to stay still during the scan.

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

• Loss of peripheral vision

• Headache

• Halos around lights

• Discomfort in the eyes

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?

• Tonometry is performed to evaluate peripheral vision.

• This test will diagnose the type of your glaucoma.

• Tonometry will allow inspection of the optic disc for signs of degeneration.

• This test will measure the intraocular pressure of the eye.

A nurse is collecting data from a client who reports shoulder pain. Which of the following findings should cause the nurse to suspect that the client has a rotator cuff injury?

• Alteration in the appearance of the shoulder joint

• Inability to abduct the arm at the shoulder

• Pallor of the affected extremity

• Numbness of the thumb and index finger

A nurse is collecting data from a client who reports wrist pain. Which of the following findings should the nurse expect if the client is experiencing carpal tunnel syndrome?

• Decreased radial pulse

• Positive Chvostek's sign

• Cool extremities

• Positive Phalen's sign

A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take?

• Weigh the client weekly.

• Irrigate the catheter as prescribed.

• Instruct the client to report an urge to urinate.

• Instruct the client to bear down as if to have a bowel movement every hour.

A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

• Urge incontinence

• Suprapubic discomfort

• Reflex incontinence

• Nocturnal enuresis

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?

• Remind the client to tell the nurse when he has to urinate.

• Use adult diapers to prevent frequent clothing changes.

• Take the client to the bathroom on an every-2-hr schedule.

• Request a prescription for an indwelling urinary catheter.