NSG210 Exam 4 Topic Guide

Exam 4 is Wednesday, December 9, 2026, and covers Weeks 11-15: neuro, liver and pancreas, kidney and urinary, male reproductive, the Week 14 online modules (disaster nursing, chronic pain and headache, newborn assessment), and endocrine. Each topic lists the textbook chapter (Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing, 15th ed.; Durham & Chapman, 4th ed.), the chapter outline, and what to know.

This first version was built from the chapter outlines before the lectures. After each lecture, add a “From the lecture” list to its topics, the same way as the Exam 3 topic guide. The syllabus uses 16th-edition chapter numbers, which are one higher than the 15th edition from Ch. 21 on (see nsg210-textbook-chapter-crosswalk).

Open question: the course calendars and the syllabus disagree on whether the liver lecture is in Week 11 or Week 12. Either way it is Exam 4 content.

Topic Map

The Week 14 chronic pain and headache module is covered under Increased ICP, headache, and migraine.

Neuro (Week 11)

Neurologic Assessment

Read: Hinkle Ch. 60. Outline: nsg210-hinkle-ch60-neurologic-assessment.

What to know:

• LOC is the most sensitive indicator of neurologic change; report any change promptly. New confusion in an older adult is delirium until proven otherwise.
• Cranial nerves: sensory I, II, VIII; motor III, IV, VI, XI, XII; mixed V, VII, IX, X.
  • Loss of the corneal reflex: protect and lubricate the eye.
  • Absent gag: NPO until a swallow evaluation.
• Grading: strength 0-5; deep tendon reflexes 0-4+, with 2+ normal. Sustained clonus or a Babinski sign in an adult means CNS disease.
• Lumbar puncture:
  • Done between L2-L3 and L4-L5 (the cord ends at L1); dangerous with suspected increased ICP or a mass.
  • A positional headache afterward is treated with lying flat, fluids, and caffeine.
• Tests:
  • CT and MRI: no metal in the MRI room; remove medication patches with foil.
  • Contrast: ask about allergies and check kidney function.
  • Angiography: watch for one-sided motor or sensory changes (embolism) and check the site.
  • EEG: hold seizure and CNS drugs 24-48 hours before as ordered; no caffeine.

From the lecture: add after the November 4 lecture.

Increased ICP, Headache, and Migraine

Read: Hinkle Ch. 61 (increased ICP, transsphenoidal surgery, seizures, headache). Outline: nsg210-hinkle-ch61-neurologic-dysfunction. This chapter also covers the Week 14 chronic pain and headache module.

What to know:

• Increased ICP:
  • A change in LOC is the earliest sign.
  • The Cushing triad (bradycardia, hypertension with a widening pulse pressure, slow irregular breathing) is a late sign of herniation. A unilateral fixed, dilated pupil means uncal herniation.
  • GCS 3-15; 8 or less means a coma and a need to protect the airway.
  • Normal ICP is 0-10 mm Hg (15 is the upper limit). CPP = MAP minus ICP; keep it over 70.
• ICP nursing:
  • HOB 30-45 degrees with the head neutral.
  • Avoid neck and hip flexion, Valsalva, clustered care, and suctioning longer than 15 seconds.
  • Mannitol or hypertonic saline for cerebral edema.
• After transsphenoidal (pituitary) surgery:
  • Clear nasal drainage that tests positive for glucose is a CSF leak.
  • Sudden high urine output with low specific gravity is diabetes insipidus.
  • No nose blowing, coughing, or bending for about a month; HOB 30 degrees.
• Seizures:
  • During a seizure: nothing in the mouth, no restraints, protect the head, side-lying afterward.
  • A seizure lasting 5 minutes or more, or back-to-back seizures, is status epilepticus: IV lorazepam or diazepam, then fosphenytoin. Abrupt anticonvulsant withdrawal is the main cause.
  • Phenytoin: gum overgrowth (oral hygiene), check drug levels.
• Headache:
  • Migraine: triptans (sumatriptan) to abort; contraindicated in ischemic heart disease and never with ergotamine.
  • Cluster headache: 100% oxygen by face mask for 15 minutes.
  • Medication-overuse headache comes from analgesics on 8-10 or more days a month.
  • Temporal (cranial) arteritis: start steroids early to prevent blindness.

From the lecture: add after the November 4 lecture and the Week 14 module.

Spinal Cord Injury

Read: Hinkle Ch. 63 (head and spinal cord injury). Outline: nsg210-hinkle-ch63-neurologic-trauma.

What to know:

• Any head injury: assume a cervical spine injury; keep the neck neutral with the collar on.
• Common SCI levels: C5-C7, T12, L1. C4 innervates the diaphragm (phrenic nerve), so injuries at C4 or above often need a ventilator.
• Report any loss of motor or sensory function at once. Ascending cord edema can cause respiratory failure.
• Neurogenic shock: hypotension and bradycardia. Vasopressors and fluids keep the MAP at 85 or higher early on. Suctioning can trigger bradycardia and cardiac arrest.
• Autonomic dysreflexia (lesions at T6 or above):
  • Sudden severe hypertension, pounding headache, bradycardia, flushing and sweating above the lesion.
  • Sit the patient up first, then find and remove the trigger, checking the bladder first, then the bowel and skin.
• Other priorities:
  • VTE prophylaxis within 72 hours for at least 3 months; never massage the legs.
  • Paralytic ileus on days 2-3.
  • Bladder program with about 2.5 L of fluid a day.
  • Skin care.
• Halo vest: if a pin comes loose, one person holds the head neutral while another calls the provider.
• Head injury signs:
  • A lucid interval followed by rapid decline is an epidural hematoma, an emergency.
  • Clear drainage from the nose or ears, or a Battle sign, means a basal skull fracture: no nasal tubes.

From the lecture: add after the November 4 lecture.

Multiple Sclerosis

Read: Hinkle Ch. 64 (neurologic infections, autoimmune disorders, neuropathies). Outline: nsg210-hinkle-ch64-neuro-infections-autoimmune.

What to know:

• MS is an immune-mediated demyelinating disease. Onset is usually ages 20-50, women 3:1. Relapsing-remitting MS is 85% of cases.
• Signs: fatigue (the most common), spasticity, visual changes, numbness, bladder and bowel problems, depression. Heat worsens symptoms, so avoid hot baths and overexertion.
• Relapse treatment: methylprednisolone 1 g IV daily for 3-5 days, then an oral taper.
• Disease-modifying drugs:
  • Interferon beta: flulike symptoms; check LFTs and WBC; depression.
  • Glatiramer: daily subcut injection.
  • Oral agents.
  • Mitoxantrone: cardiotoxic, with a lifetime dose limit.
• Spasticity: baclofen.
• Screen for depression and suicide risk; major depression affects about half of patients.
• Related disorders in the same chapter:
  • Myasthenia gravis: give pyridostigmine on time. A falling vital capacity is the first sign of crisis.
  • Guillain-Barre syndrome: ascending weakness; track vital capacity; cognition stays intact.
  • Bacterial meningitis: emergent antibiotics and droplet precautions for 24 hours.

From the lecture: add after the November 4 lecture.

Parkinson Disease

Read: Hinkle Ch. 65 (oncologic and degenerative neurologic disorders). Outline: nsg210-hinkle-ch65-degenerative-neuro.

What to know:

• Cause: loss of dopamine neurons. Symptoms appear after about 80% of dopamine is lost.
• Classic signs: resting tremor, rigidity, bradykinesia, postural instability and a shuffling gait, masklike face, soft voice, drooling.
• Drugs:
  • Carbidopa-levodopa is the mainstay. After 5-10 years it causes dyskinesia and the “on-off” effect, plus nausea, orthostatic hypotension, and confusion.
  • Anticholinergics (benztropine, trihexyphenidyl) for tremor: constipation and urinary retention; contraindicated in narrow-angle glaucoma.
  • Others: dopamine agonists (ropinirole, pramipexole), MAO-B inhibitors (selegiline), amantadine.
• Nursing priorities:
  • Aspiration: sit upright, thickened liquids.
  • Falls: wide-based gait.
  • Orthostatic hypotension.
  • Constipation and nutrition.
• Same chapter:
  • Brain tumors: a morning headache worse with straining, projectile vomiting, papilledema.
  • ALS and Huntington disease.
  • After spinal surgery: logroll and check strength.
  • After cervical discectomy: neck swelling with airway risk.

From the lecture: add after the November 4 lecture.

Nutrition (Week 12)

Hepatitis, Cirrhosis, and Liver Cancer

Read: Hinkle Ch. 43. Outline: nsg210-hinkle-ch43-hepatic-disorders.

What to know:

• Viral hepatitis:

• Hepatitis care: rest, nutrition, and no alcohol for 6 months after recovery. Jaundice shows when bilirubin is over 2 mg/dL.
• Cirrhosis complications:
  • Ascites:
    • 2 g sodium diet and diuretics.
    • Daily weight, with no more than 1 kg of loss a day.
    • Before paracentesis, have the patient void.
    • Fever with abdominal pain suggests spontaneous bacterial peritonitis.
  • Varices:
    • Hematemesis, melena, hypotension, and tachycardia mean a variceal bleed: ICU, octreotide, endoscopy (banding).
    • Balloon tamponade needs an airway first.
    • Beta-blockers are for prevention, not acute bleeding.
  • Hepatic encephalopathy:
    • Confusion, day-night reversal, asterixis, worsening handwriting.
    • Lactulose to 2-3 soft stools a day; watery diarrhea means too much (check potassium).
    • Do not restrict protein.
    • Hold sedatives and find the trigger (bleeding, infection, low potassium, constipation).
  • Bleeding precautions (low clotting factors): soft toothbrush, electric razor, pressure on puncture sites.
• Liver cancer: AFP is elevated in most cases. Treatment includes resection, ablation, and transplant.

From the lecture: add after the liver lecture.

Pancreatitis and Pancreatic Cancer

Read: Hinkle Ch. 44 (biliary disorders and pancreas). Outline: nsg210-hinkle-ch44-biliary-pancreatic.

What to know:

• Acute pancreatitis:
  • About 80% are from gallstones or alcohol.
  • Diagnosed by amylase or lipase over 3 times normal; lipase stays up longer.
  • Severe epigastric pain radiating to the back.
• Danger signs:
  • Hypotension, tachycardia, and falling urine output mean hypovolemic shock: give aggressive IV fluids.
  • A boardlike abdomen means peritonitis.
  • Flank or umbilical bruising means severe pancreatitis.
  • Hypocalcemia (tetany): keep IV calcium available.
  • Hypoxemia is common: semi-Fowler position, cough and deep breathing.
• Pancreatitis care: pain control, NPO or early enteral feeding as ordered, and glucose monitoring.
• Chronic pancreatitis: mostly from alcohol. Fatty stools, weight loss, diabetes; give pancreatic enzymes with meals.
• Pancreatic cancer:
  • Most are in the head of the pancreas, with painless jaundice.
  • New diabetes with weight loss and back pain in an older adult is a warning sign.
  • Very poor survival.
• Gallbladder (same chapter):
  • Right upper quadrant pain to the right shoulder after a fatty meal is biliary colic.
  • After a laparoscopic cholecystectomy, shoulder pain is from gas. Fever, vomiting, and increasing pain may mean a bile leak.

From the lecture: add after the liver lecture.

Elimination (Week 13)

Pyelonephritis, Kidney Stones, and Bladder Cancer

Read: Hinkle Ch. 49 (urinary disorders). Outline: nsg210-hinkle-ch49-urinary-disorders.

What to know:

• Acute pyelonephritis:
  • Fever, chills, flank pain, CVA tenderness, nausea and vomiting, urinary symptoms.
  • Check for obstruction.
  • About 2 weeks of antibiotics, with a follow-up culture.
  • Fluids of 3-4 L a day unless contraindicated.
• Chronic pyelonephritis scars the kidneys and can lead to CKD.
• UTI teaching:
  • Wipe front to back, showers rather than tub baths, void often, plenty of fluids, avoid bladder irritants.
  • In an older adult, new confusion may be a UTI.
  • A catheterized patient with fever, hypotension, and confusion has urosepsis.
• Kidney stones:
  • Severe colic: opioids plus NSAIDs.
  • Strain all urine.
  • Fluids to dilute the urine.
  • Diet depends on stone type: limit sodium and excess protein; limit oxalate for oxalate stones.
  • After lithotripsy, strain the urine and watch for obstruction and infection.
  • A stone with infection or obstruction risks urosepsis.
• Bladder cancer:
  • Painless visible hematuria is the most common sign. Tobacco is the leading risk, plus dye and chemical exposure.
  • Biopsy is definitive.
  • Transurethral resection, then intravesical BCG.
  • Lifelong surveillance cystoscopy.
• Urinary diversion: a purple, brown, or black stoma must be reported at once. Less urine with more drain output means a leak.

From the lecture: add after the November 18 lecture.

Kidney Cancer and Kidney Tests

Read: Hinkle Ch. 47 (assessment) and Ch. 48 (kidney disorders, including kidney cancer). Outlines: nsg210-hinkle-ch47-kidney-urinary-assessment, nsg210-hinkle-ch48-kidney-disorders.

What to know:

• Kidney cancer:
  • About 90% are renal cell carcinoma; over half are found by chance.
  • Smoking is a risk.
  • Radical or partial nephrectomy.
• After kidney surgery: watch for hemorrhage and shock; no output from a drain means obstruction.
• Tests:
  • Contrast studies: ask about allergies, check kidney function, hold metformin and NSAIDs, hydrate.
  • After a kidney biopsy: watch for bleeding (vital signs, flank pain), bed rest, compare urine samples.
  • Draw PSA before the DRE.
  • Small, frequent voids with urgency suggest retention: bladder scan.
• General kidney points:
  • Daily weight is the best measure of fluid status.
  • Hyperkalemia (peaked T waves): IV calcium, insulin with dextrose, then dialysis.
  • Dialysis access arm: no BP, IVs, or blood draws; check for a thrill and bruit.

From the lecture: add after the November 18 lecture.

BPH and Prostate Cancer

Read: Hinkle Ch. 53 (male reproductive disorders). Outline: nsg210-hinkle-ch53-male-reproductive.

What to know:

• BPH:
  • Frequency, urgency, nocturia, hesitancy, a weak stream, and a feeling of incomplete emptying.
  • On DRE the prostate is large, rubbery, and nontender.
  • Acute retention: catheterize at once.
• BPH drugs:
  • Alpha blockers (tamsulosin, doxazosin, terazosin) relax smooth muscle; watch for orthostatic hypotension and dizziness.
  • 5-alpha-reductase inhibitors (finasteride, dutasteride) shrink the prostate; sexual side effects.
• TURP is the standard surgery for BPH. Continuous bladder irrigation keeps clots out. Watch for:
  • Bright red urine with clots, a rising pulse, and falling BP: arterial hemorrhage; notify the surgeon.
  • Irrigation in that doesn’t come out, suprapubic swelling, or spasms: an obstructed catheter.
  • Confusion, nausea, seizures, and BP changes: TUR syndrome (hyponatremia, fluid overload).
• Prostate cancer:
  • The most common male cancer, often silent.
  • PSA is sensitive but not specific; screen with PSA plus DRE; biopsy is needed for diagnosis.
  • Treatment: surgery, radiation, androgen deprivation.
  • Bone pain may mean metastasis: fall precautions.
  • After perineal prostatectomy, no rectal temperatures, tubes, or enemas.
• Same chapter:
  • Testicular torsion is a surgical emergency (6-hour window).
  • A painless testicular lump needs prompt evaluation.
  • PDE5 inhibitors are contraindicated with nitrates.

From the lecture: add after the November 18 lecture.

Online Modules (Week 14)

Disaster Nursing

Read: Hinkle Ch. 68 (chemical and radiological agents). Outline: nsg210-hinkle-ch68-disaster-nursing.

What to know:

• Triage: the greatest good for the greatest number. Expectant (black) patients are separated and comforted, not abandoned.
• Protection and decontamination:
  • Put on PPE before contact.
  • Decontaminate before entry: removing clothing removes most contamination, then rinse and wash with soap and water. Never assume field decontamination was complete.
• Radiation:
  • Treat life threats first, then limit exposure: time, distance, shielding.
  • A patient exposed to external radiation is not radioactive.
  • Neurologic symptoms after radiation suggest a lethal dose.
• Chemical agents:
  • Move to fresh air and stand up; most agents are heavier than air.
  • Nerve agents: pinpoint pupils, secretions, bradycardia, twitching. Give atropine until secretions dry; blot, don’t wipe.
  • Cyanide: bright red skin.
  • Blister agents: soap and water, blot, no scrubbing or bleach.
• Biological agents:
  • Botulism: descending paralysis in an alert patient; watch the airway.
  • Inhalation anthrax: not contagious.
  • Smallpox: airborne and contact precautions, negative pressure.
  • Pneumonic plague: droplet precautions.

From the module: add after the November 25 module.

Newborn Assessment

Read: Durham Ch. 15. Outline: nsg210-durham-ch15-neonate-and-family. This chapter was also Exam 3 content; the newborn section of the Exam 3 topic guide has the lecture points.

What to know:

• Warmth: dry the baby immediately and prevent all four kinds of heat loss.
  • A cold or jittery infant: check glucose first.
  • Sick newborns become hypothermic, not febrile.
• Report:
  • Central cyanosis after 10 minutes; grunting, flaring, retractions, or RR over 60.
  • Jaundice in the first 24 hours.
  • No void in 24 hours, or no meconium in 48 hours.
  • Femoral pulses weaker than brachial pulses (possible heart defect).
• Fontanels: bulging at rest means increased ICP; sunken means dehydration.
• Moro reflex: asymmetric after shoulder dystocia means checking the clavicle and brachial plexus.
• Safety:
  • ID bands before separation.
  • Back to sleep, no bed-sharing or soft bedding.
  • Never shake a baby.
• Circumcision care: no petroleum jelly with a Plastibell; petroleum jelly at each change after a Gomco or Mogen clamp.

From the module: add after the November 25 module.

Regulation and Metabolism (Week 15)

Endocrine: Pituitary, Thyroid, Parathyroid, Adrenal

Read: Hinkle Ch. 45 (endocrine disorders); transsphenoidal surgery is in Ch. 61. Outline: nsg210-hinkle-ch45-endocrine-disorders.

What to know:

• Hypothyroidism:
  • Fatigue, cold intolerance, weight gain, slow heart rate.
  • Levothyroxine: start low in older adults, because it can cause angina.
  • Sedatives and opioids at reduced doses.
  • Myxedema coma: passive rewarming only.
• Hyperthyroidism (Graves):
  • Heat intolerance, weight loss, tachycardia, exophthalmos.
  • PTU or methimazole: sore throat or fever means stop the drug and check a CBC (agranulocytosis).
  • Radioactive iodine: pregnancy test first.
• Thyroid storm:
  • Temperature over 38.5 C and HR over 130.
  • Cool the patient; acetaminophen, not aspirin.
  • Oxygen, antithyroid drugs, iodine, hydrocortisone, beta-blocker.
• After thyroidectomy:
  • Airway first, with a tracheostomy set at the bedside.
  • Neck pressure, bleeding behind the neck, stridor, or a voice change: call the surgeon.
  • Tingling or carpopedal spasm (hypocalcemia from parathyroid injury): IV calcium gluconate.
• Parathyroid:
  • Hyperparathyroidism (high calcium): push fluids, keep mobile, avoid thiazides; risk of kidney stones.
  • Hypoparathyroidism (low calcium): Trousseau and Chvostek signs; calcium replacement.
• Adrenal:
  • Addisonian crisis: IV hydrocortisone and saline. Never stop steroids abruptly; give stress doses.
  • Cushing syndrome or long-term steroids: infection signs are masked; check glucose and potassium; fracture prevention; give steroids in the morning.
  • Pheochromocytoma: alpha blocker before beta blocker.

From the lecture: add after the December 2 lecture.

Related

• nsg210-exam-3-topic-guide
• Chapter index
• nsg210-textbook-chapter-crosswalk