NUR 265 Exam 3: Key Concepts and
Priorities in TBI and Shock Management
| 47 Questions and Answers | Fall
2025/2026 Update | 100% Correct
NUR 265 Exam 3
1. The nurse is working in the emergency department (ED) is admitting a
client who has sustained a traumatic brain injury (TBI) following a
motor vehicle crash. It is a Priority for the nurse to notify the primary
healthcare provider (PHCP) in the client:
A) Reports having a continuous headache
B) Has a blood pressure of 162/94 mm Hg
C) Is unable to remember the crash
D) Takes prescribed warfarin daily
(Bleeding risk from primary TBI, possible head trauma. Pg 942)
2. The charge nurse is observing a newly hired nurse care for a client who
sustained a closed head injury is receiving mechanical ventilation, and
is at risk for developing ICP. Which of the following actions, if
performed by the newly hired nurse, requires intervention by the
charge nurse?
A) Using the bag-valve mask on the client when the low pressure alarm
sounds
B) Raising the foot of the client’s bed
C) Setting up suction equipment at bedside
D) Maintaining the client’s head at midline, neutral position.
(By raising it, it decreases venous return that will result in increased
ICP)
3. The newly hired nurse is caring for a client who was admitted 12 hours
ago with a TBI and is at risk for developing ICP. It requires intervention
by the nurse preceptor if the newly hired nurse is observed:
A) Instructing the client not to assist during positioning
mailto:https://www.stuvia.com/user/Wisdoms
, B) Checking the client’s VS every hour
C) Clustering client care activities
D) Encouraging the client’s visitors not to stimulate the client
(Can increase ICP dramatically. On PowerPoint)
mailto:https://www.stuvia.com/user/Wisdoms
, 4. The nurse is caring for assigned clients. Which of the following
assessment findings requires the nurse to notify the PHCP?
A) An output of 30mL from the surgical drain of a client who had a
craniotomy 6 hours ago
B) A decrease in the Glasgow coma scale (GCS) from a 4 to 3 in a
client who has a brain tumor
C) A report of tinnitus by a client who was recently diagnosed with an
acoustic neuroma
D) The development of asymmetric pupils with no reaction to light in a
client who has a TBI
(s/s of increasing ICP) (Changes to GCS of 2 or more is clinically
important. Tinnitus expected. 30-50mL normal) pg. 946, 957
5. The nurse is assessing clients for the risk of sustaining TBI. Which of
the following clients should the nurse identify as being at greatest risk?
A) 45-year-old who has epilepsy and takes phenytoin
B) 20-year-old college student who participates on the football team
C) 7-year-old who is learning how to ride a bicycle without training
wheels
D) 60-year-old who lives alone and wears a hearing aid
(Sport injuries, colliding with stationary or moving objects. Pg. 943)
6. **The nurse is caring for a client who had a TBI with skull fracture. The
nurse noted that the client has developed rhinorrhea that is positive for
glucose. Which of the following actions should the nurse take next?
A) Apply a drip pad to the client’s nose
B) Perform a halo sign test
C) Prepare to suction the client
D) Notify the PHCP
(pg. 946)
mailto:https://www.stuvia.com/user/Wisdoms
Priorities in TBI and Shock Management
| 47 Questions and Answers | Fall
2025/2026 Update | 100% Correct
NUR 265 Exam 3
1. The nurse is working in the emergency department (ED) is admitting a
client who has sustained a traumatic brain injury (TBI) following a
motor vehicle crash. It is a Priority for the nurse to notify the primary
healthcare provider (PHCP) in the client:
A) Reports having a continuous headache
B) Has a blood pressure of 162/94 mm Hg
C) Is unable to remember the crash
D) Takes prescribed warfarin daily
(Bleeding risk from primary TBI, possible head trauma. Pg 942)
2. The charge nurse is observing a newly hired nurse care for a client who
sustained a closed head injury is receiving mechanical ventilation, and
is at risk for developing ICP. Which of the following actions, if
performed by the newly hired nurse, requires intervention by the
charge nurse?
A) Using the bag-valve mask on the client when the low pressure alarm
sounds
B) Raising the foot of the client’s bed
C) Setting up suction equipment at bedside
D) Maintaining the client’s head at midline, neutral position.
(By raising it, it decreases venous return that will result in increased
ICP)
3. The newly hired nurse is caring for a client who was admitted 12 hours
ago with a TBI and is at risk for developing ICP. It requires intervention
by the nurse preceptor if the newly hired nurse is observed:
A) Instructing the client not to assist during positioning
mailto:https://www.stuvia.com/user/Wisdoms
, B) Checking the client’s VS every hour
C) Clustering client care activities
D) Encouraging the client’s visitors not to stimulate the client
(Can increase ICP dramatically. On PowerPoint)
mailto:https://www.stuvia.com/user/Wisdoms
, 4. The nurse is caring for assigned clients. Which of the following
assessment findings requires the nurse to notify the PHCP?
A) An output of 30mL from the surgical drain of a client who had a
craniotomy 6 hours ago
B) A decrease in the Glasgow coma scale (GCS) from a 4 to 3 in a
client who has a brain tumor
C) A report of tinnitus by a client who was recently diagnosed with an
acoustic neuroma
D) The development of asymmetric pupils with no reaction to light in a
client who has a TBI
(s/s of increasing ICP) (Changes to GCS of 2 or more is clinically
important. Tinnitus expected. 30-50mL normal) pg. 946, 957
5. The nurse is assessing clients for the risk of sustaining TBI. Which of
the following clients should the nurse identify as being at greatest risk?
A) 45-year-old who has epilepsy and takes phenytoin
B) 20-year-old college student who participates on the football team
C) 7-year-old who is learning how to ride a bicycle without training
wheels
D) 60-year-old who lives alone and wears a hearing aid
(Sport injuries, colliding with stationary or moving objects. Pg. 943)
6. **The nurse is caring for a client who had a TBI with skull fracture. The
nurse noted that the client has developed rhinorrhea that is positive for
glucose. Which of the following actions should the nurse take next?
A) Apply a drip pad to the client’s nose
B) Perform a halo sign test
C) Prepare to suction the client
D) Notify the PHCP
(pg. 946)
mailto:https://www.stuvia.com/user/Wisdoms
