1
ATI MEDSURG 2 NUR 265 Actual Exam
2026/2027 Complete Questions and Verified
Answers Neuro Shock Burns Practice Pass
Guaranteed - A+ Graded
SECTION 1: NEUROLOGICAL DISORDERS (25 Questions)
Question 1 (Neuro)
A 24-year-old client is admitted following a motor vehicle accident with a Glasgow Coma Scale
(GCS) score of 8. The nurse notes that the client's right pupil is dilated and nonreactive. Which
intervention is the priority?
A) Administer mannitol 1 g/kg IV bolus
B) Elevate the head of the bed to 30 degrees
C) Prepare for emergent intubation
D) Obtain a STAT CT scan of the head
Correct Answer: A
Detailed Rationale: This client presents with signs of increased intracranial pressure (ICP)
and impending brain herniation. The GCS of 8 indicates severe neurological impairment (eye
opening 2, verbal response 2, motor response 4 = 8), and the unilateral dilated, nonreactive pupil
("blown pupil") suggests uncal herniation with compression of the third cranial nerve.
Pathophysiology: Uncal herniation occurs when the medial temporal lobe (uncus) shifts
downward through the tentorial incisura, compressing the ipsilateral oculomotor nerve (CN III)
and eventually the brainstem. This is a neurosurgical emergency requiring immediate ICP
reduction.
Clinical Reasoning: While all options are appropriate interventions, mannitol administration
is the priority because:
• It creates an osmotic gradient that draws fluid from brain tissue into the vasculature
• It reduces blood viscosity, improving cerebral blood flow and oxygenation
,2
• It must be given emergently to prevent irreversible brainstem compression
Why Other Options Are Incorrect:
• B: Head elevation helps venous drainage but does not address the acute herniation
• C: Intubation protects the airway (GCS ≤8 requires airway protection), but mannitol must
be given simultaneously or first to prevent brainstem compression during intubation
• D: CT scan confirms diagnosis but delays critical treatment; imaging occurs after
stabilization
Key Point: A unilateral dilated, nonreactive pupil in a head trauma patient indicates uncal
herniation—administer hyperosmolar therapy (mannitol or hypertonic saline) immediately while
preparing for definitive surgical intervention.
Question 2 (Neuro)
A client with a traumatic brain injury has an intraventricular catheter (ventriculostomy) for ICP
monitoring. The current reading is 22 mmHg. Which nursing action is appropriate?
A) Drain 10 mL of CSF to reduce the pressure
B) Ensure the transducer is level with the foramen of Monro
C) Administer a sedative to decrease cerebral metabolic demand
D) Lower the head of the bed to improve cerebral perfusion
Correct Answer: B
Detailed Rationale: Normal ICP is 0-15 mmHg; 22 mmHg indicates elevated ICP but not yet
critical (>20 mmHg requires intervention). The nurse must first verify measurement accuracy
before treating.
Pathophysiology: ICP monitoring requires the transducer to be zeroed at the foramen of Monro
(external auditory meatus level) to ensure accurate readings. An improperly leveled transducer
yields false readings that could lead to inappropriate interventions.
Clinical Reasoning:
• Option B is correct because accurate measurement is foundational to all subsequent
decisions
• The foramen of Monro represents the level of the third ventricle, the standard reference
point for ICP monitoring
Why Other Options Are Incorrect:
• A: CSF drainage requires a physician order; nurses cannot independently drain CSF
,3
• C: While sedation may be appropriate, verify the reading first—if the transducer is
malpositioned, the "elevated" ICP may be artifact
• D: Lowering the head increases ICP by impairing venous drainage; the head should be
elevated 30 degrees
Key Point: Always verify equipment accuracy (transducer level, zeroing) before treating
abnormal ICP readings to prevent interventions based on erroneous data.
Question 3 (Neuro) - Select All That Apply
A nurse is caring for a client with increased ICP. Which interventions are appropriate to prevent
further increases in pressure? (Select all that apply.)
A) Maintain head in midline position
B) Suction the endotracheal tube every 2 hours routinely
C) Cluster nursing activities to allow rest periods
D) Administer antipyretics for temperature >38°C (100.4°F)
E) Prevent constipation and straining during bowel movements
F) Keep the neck flexed to promote venous drainage
Correct Answers: A, D, E
Detailed Rationale: ICP management requires minimizing factors that increase cerebral blood
volume or metabolic demand.
Pathophysiology: ICP is determined by brain tissue volume, cerebrospinal fluid volume, and
cerebral blood volume. Any intervention affecting these components impacts ICP.
Correct Interventions:
• A: Midline head position prevents jugular venous compression, facilitating venous
outflow and reducing cerebral blood volume
• D: Fever increases cerebral metabolic demand by 10-13% per 1°C, increasing blood flow
and ICP; normothermia is essential
• E: Straining (Valsalva maneuver) increases intrathoracic pressure, impeding venous
return and raising ICP; stool softeners prevent this
Why Other Options Are Incorrect:
• B: Routine suctioning is contraindicated—suctioning triggers cough/gag reflexes, raising
ICP. Suction only when clinically indicated using preoxygenation and limiting passes to
10 seconds
, 4
• C: Clustering activities is incorrect—space activities to prevent cumulative ICP spikes;
allow 30-60 minutes between interventions
• F: Neck flexion compresses jugular veins, impeding drainage and increasing ICP;
maintain neutral alignment
Key Point: ICP management follows the "5 Hs": Head midline, Hydration (euvolemia),
Hyperventilation (short-term only), Hypothermia prevention, and Hemodynamic stability—avoid
clustering care, Valsalva maneuvers, and jugular compression.
Question 4 (Neuro)
A client presents to the ED 30 minutes after a head injury. The nurse observes a "lucid interval"
in the client's history—conscious initially, then deteriorating. Which type of hematoma is most
likely?
A) Subdural hematoma
B) Epidural hematoma
C) Intracerebral hematoma
D) Subarachnoid hemorrhage
Correct Answer: B
Detailed Rationale: The lucid interval (temporary consciousness followed by rapid
deterioration) is pathognomonic for epidural hematoma (EDH).
Pathophysiology: EDH typically results from middle meningeal artery laceration (arterial
bleeding) secondary to temporal bone fracture. Arterial bleeding accumulates rapidly between
the skull and dura mater, creating a lens-shaped mass on CT. The initial injury causes concussion
(brief LOC), followed by a lucid interval as the hematoma expands. As ICP rises, the client
deteriorates rapidly—"talk and die" syndrome.
Clinical Reasoning:
• EDH = Arterial bleeding = Rapid expansion = Lucid interval
• Requires emergent craniotomy for hematoma evacuation
Why Other Options Are Incorrect:
• A: Subdural hematoma (SDH) involves venous bleeding (bridging veins), develops
slowly (hours-days), and typically occurs in elderly or alcoholics without a lucid interval;
appears crescent-shaped on CT
• C: Intracerebral hematoma causes immediate focal deficits without lucid interval
ATI MEDSURG 2 NUR 265 Actual Exam
2026/2027 Complete Questions and Verified
Answers Neuro Shock Burns Practice Pass
Guaranteed - A+ Graded
SECTION 1: NEUROLOGICAL DISORDERS (25 Questions)
Question 1 (Neuro)
A 24-year-old client is admitted following a motor vehicle accident with a Glasgow Coma Scale
(GCS) score of 8. The nurse notes that the client's right pupil is dilated and nonreactive. Which
intervention is the priority?
A) Administer mannitol 1 g/kg IV bolus
B) Elevate the head of the bed to 30 degrees
C) Prepare for emergent intubation
D) Obtain a STAT CT scan of the head
Correct Answer: A
Detailed Rationale: This client presents with signs of increased intracranial pressure (ICP)
and impending brain herniation. The GCS of 8 indicates severe neurological impairment (eye
opening 2, verbal response 2, motor response 4 = 8), and the unilateral dilated, nonreactive pupil
("blown pupil") suggests uncal herniation with compression of the third cranial nerve.
Pathophysiology: Uncal herniation occurs when the medial temporal lobe (uncus) shifts
downward through the tentorial incisura, compressing the ipsilateral oculomotor nerve (CN III)
and eventually the brainstem. This is a neurosurgical emergency requiring immediate ICP
reduction.
Clinical Reasoning: While all options are appropriate interventions, mannitol administration
is the priority because:
• It creates an osmotic gradient that draws fluid from brain tissue into the vasculature
• It reduces blood viscosity, improving cerebral blood flow and oxygenation
,2
• It must be given emergently to prevent irreversible brainstem compression
Why Other Options Are Incorrect:
• B: Head elevation helps venous drainage but does not address the acute herniation
• C: Intubation protects the airway (GCS ≤8 requires airway protection), but mannitol must
be given simultaneously or first to prevent brainstem compression during intubation
• D: CT scan confirms diagnosis but delays critical treatment; imaging occurs after
stabilization
Key Point: A unilateral dilated, nonreactive pupil in a head trauma patient indicates uncal
herniation—administer hyperosmolar therapy (mannitol or hypertonic saline) immediately while
preparing for definitive surgical intervention.
Question 2 (Neuro)
A client with a traumatic brain injury has an intraventricular catheter (ventriculostomy) for ICP
monitoring. The current reading is 22 mmHg. Which nursing action is appropriate?
A) Drain 10 mL of CSF to reduce the pressure
B) Ensure the transducer is level with the foramen of Monro
C) Administer a sedative to decrease cerebral metabolic demand
D) Lower the head of the bed to improve cerebral perfusion
Correct Answer: B
Detailed Rationale: Normal ICP is 0-15 mmHg; 22 mmHg indicates elevated ICP but not yet
critical (>20 mmHg requires intervention). The nurse must first verify measurement accuracy
before treating.
Pathophysiology: ICP monitoring requires the transducer to be zeroed at the foramen of Monro
(external auditory meatus level) to ensure accurate readings. An improperly leveled transducer
yields false readings that could lead to inappropriate interventions.
Clinical Reasoning:
• Option B is correct because accurate measurement is foundational to all subsequent
decisions
• The foramen of Monro represents the level of the third ventricle, the standard reference
point for ICP monitoring
Why Other Options Are Incorrect:
• A: CSF drainage requires a physician order; nurses cannot independently drain CSF
,3
• C: While sedation may be appropriate, verify the reading first—if the transducer is
malpositioned, the "elevated" ICP may be artifact
• D: Lowering the head increases ICP by impairing venous drainage; the head should be
elevated 30 degrees
Key Point: Always verify equipment accuracy (transducer level, zeroing) before treating
abnormal ICP readings to prevent interventions based on erroneous data.
Question 3 (Neuro) - Select All That Apply
A nurse is caring for a client with increased ICP. Which interventions are appropriate to prevent
further increases in pressure? (Select all that apply.)
A) Maintain head in midline position
B) Suction the endotracheal tube every 2 hours routinely
C) Cluster nursing activities to allow rest periods
D) Administer antipyretics for temperature >38°C (100.4°F)
E) Prevent constipation and straining during bowel movements
F) Keep the neck flexed to promote venous drainage
Correct Answers: A, D, E
Detailed Rationale: ICP management requires minimizing factors that increase cerebral blood
volume or metabolic demand.
Pathophysiology: ICP is determined by brain tissue volume, cerebrospinal fluid volume, and
cerebral blood volume. Any intervention affecting these components impacts ICP.
Correct Interventions:
• A: Midline head position prevents jugular venous compression, facilitating venous
outflow and reducing cerebral blood volume
• D: Fever increases cerebral metabolic demand by 10-13% per 1°C, increasing blood flow
and ICP; normothermia is essential
• E: Straining (Valsalva maneuver) increases intrathoracic pressure, impeding venous
return and raising ICP; stool softeners prevent this
Why Other Options Are Incorrect:
• B: Routine suctioning is contraindicated—suctioning triggers cough/gag reflexes, raising
ICP. Suction only when clinically indicated using preoxygenation and limiting passes to
10 seconds
, 4
• C: Clustering activities is incorrect—space activities to prevent cumulative ICP spikes;
allow 30-60 minutes between interventions
• F: Neck flexion compresses jugular veins, impeding drainage and increasing ICP;
maintain neutral alignment
Key Point: ICP management follows the "5 Hs": Head midline, Hydration (euvolemia),
Hyperventilation (short-term only), Hypothermia prevention, and Hemodynamic stability—avoid
clustering care, Valsalva maneuvers, and jugular compression.
Question 4 (Neuro)
A client presents to the ED 30 minutes after a head injury. The nurse observes a "lucid interval"
in the client's history—conscious initially, then deteriorating. Which type of hematoma is most
likely?
A) Subdural hematoma
B) Epidural hematoma
C) Intracerebral hematoma
D) Subarachnoid hemorrhage
Correct Answer: B
Detailed Rationale: The lucid interval (temporary consciousness followed by rapid
deterioration) is pathognomonic for epidural hematoma (EDH).
Pathophysiology: EDH typically results from middle meningeal artery laceration (arterial
bleeding) secondary to temporal bone fracture. Arterial bleeding accumulates rapidly between
the skull and dura mater, creating a lens-shaped mass on CT. The initial injury causes concussion
(brief LOC), followed by a lucid interval as the hematoma expands. As ICP rises, the client
deteriorates rapidly—"talk and die" syndrome.
Clinical Reasoning:
• EDH = Arterial bleeding = Rapid expansion = Lucid interval
• Requires emergent craniotomy for hematoma evacuation
Why Other Options Are Incorrect:
• A: Subdural hematoma (SDH) involves venous bleeding (bridging veins), develops
slowly (hours-days), and typically occurs in elderly or alcoholics without a lucid interval;
appears crescent-shaped on CT
• C: Intracerebral hematoma causes immediate focal deficits without lucid interval
