NUR 265 Exam 3 | Key Concepts & Priorities In TBI And Shock Management, Questions
& Verified Answers 2026-27 Update
The nurse is working in the emergency department and is admitting a client who has a sustained TBI,
following a motor vehicle crash, it is a priority for the nurse to notify the primary health care provider if
the client
takes prescribed warfarin daily
The charge nurse observes a newly hired nurse caring 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?
raising the foot of the clients bed
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
Clustering client care activities
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?
20 yr old college student who participates on the football team
The nurse is caring for assigned clients. Which of the following assessment findings requires the
nurse to notify the PHCP?
the development of asymmetric pupils with no reaction to light in the client who has the TBI
The nurse is caring for a client with a TBI and a skull fracture. The nurse noted that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following actions should the
nurse take next?
Perform a halo sign test
The nurse is providing discharge instructions to a client's partner who sustained a mild head
injury due to an MVA. Which of the following statements, if made by the partners, would indicate
the need for additional teaching?
i will bring my partner to the ED if they immediately starting vomiting
The nurse is caring for the following assigned clients. Which client should the nurse see first?
The client who has brain injusry and bp change from 110/58 to 134/40
1
, The nurse is caring for a client who is 24 hours post-op following a craniotomy. The client is
reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which of the following actions
should the nurse take?
Perform a neurological test
The nurse is caring for a client who has encephalitis. It is priority for the nurse to follow up if the
client
has a change in BP from 120/78 to 130/60
The nurse is caring for a client who has been admitted with suspected bacterial meningitis. Which
of the following actions should the nurse take first?
Prepare the client for a lumbar puncture
The nurse is caring for the client who has confusion, fever, headache, blurred vision, NV, and a
history of HIV. Which of the following actions should the nurse take first?
implement seizure precautions
Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports blurred vision, BP 145/95,
HR 68, O2 95%. Which of the following actions should the nurse take?
palpate the clients bladder (Autonomic dysreflexia)
The nurse working in the ED is caring for a client admitted with a suspected spinal cord injury. It
would require follow up by the nurse if the PHCP prescribed which of the following?
Mannitol
The nurse has taught a client who has myasthenia gravis about taking their prescribed
medications on time and 45-60 mins prior to meals. The client asks why timing is so important. Which
of the following is an appropriate response by the nurse?
this allows the medication to have maximum effect, so its easier to swallow
The nurse is working in the ED is caring for a client who has MG. The client presents with muscle
weakness, NVD, and pulse of 58. Which of the following medications should the nurse admin
immediately?
Atropine sulfate
The nurse preceptor is observing a newly hired nurse care for a client who has MG. Which of the
following actions by the newly hired nurse requires immediate intervention by the nurse preceptor?
2
& Verified Answers 2026-27 Update
The nurse is working in the emergency department and is admitting a client who has a sustained TBI,
following a motor vehicle crash, it is a priority for the nurse to notify the primary health care provider if
the client
takes prescribed warfarin daily
The charge nurse observes a newly hired nurse caring 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?
raising the foot of the clients bed
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
Clustering client care activities
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?
20 yr old college student who participates on the football team
The nurse is caring for assigned clients. Which of the following assessment findings requires the
nurse to notify the PHCP?
the development of asymmetric pupils with no reaction to light in the client who has the TBI
The nurse is caring for a client with a TBI and a skull fracture. The nurse noted that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following actions should the
nurse take next?
Perform a halo sign test
The nurse is providing discharge instructions to a client's partner who sustained a mild head
injury due to an MVA. Which of the following statements, if made by the partners, would indicate
the need for additional teaching?
i will bring my partner to the ED if they immediately starting vomiting
The nurse is caring for the following assigned clients. Which client should the nurse see first?
The client who has brain injusry and bp change from 110/58 to 134/40
1
, The nurse is caring for a client who is 24 hours post-op following a craniotomy. The client is
reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which of the following actions
should the nurse take?
Perform a neurological test
The nurse is caring for a client who has encephalitis. It is priority for the nurse to follow up if the
client
has a change in BP from 120/78 to 130/60
The nurse is caring for a client who has been admitted with suspected bacterial meningitis. Which
of the following actions should the nurse take first?
Prepare the client for a lumbar puncture
The nurse is caring for the client who has confusion, fever, headache, blurred vision, NV, and a
history of HIV. Which of the following actions should the nurse take first?
implement seizure precautions
Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports blurred vision, BP 145/95,
HR 68, O2 95%. Which of the following actions should the nurse take?
palpate the clients bladder (Autonomic dysreflexia)
The nurse working in the ED is caring for a client admitted with a suspected spinal cord injury. It
would require follow up by the nurse if the PHCP prescribed which of the following?
Mannitol
The nurse has taught a client who has myasthenia gravis about taking their prescribed
medications on time and 45-60 mins prior to meals. The client asks why timing is so important. Which
of the following is an appropriate response by the nurse?
this allows the medication to have maximum effect, so its easier to swallow
The nurse is working in the ED is caring for a client who has MG. The client presents with muscle
weakness, NVD, and pulse of 58. Which of the following medications should the nurse admin
immediately?
Atropine sulfate
The nurse preceptor is observing a newly hired nurse care for a client who has MG. Which of the
following actions by the newly hired nurse requires immediate intervention by the nurse preceptor?
2
