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NUR2755 Final Exam: Multidimensional Care IV
(MDC 4)
Latest 2026/2027 Edition | 100+ Practice Questions
with Verified Answers & Detailed Rationales
Section 1: Neurological Disorders (Questions 1-25)
Question 1: A client with a traumatic brain injury (TBI) has an
intracranial pressure (ICP) reading of 22 mm Hg. What is the nurse's
priority action?
A) Administer oxygen at 2 L/min via nasal cannula
B) Notify the healthcare provider immediately
C) Encourage deep breathing and coughing
D) Administer prescribed analgesics
Answer: B) Notify the healthcare provider immediately
Rationale: An ICP above 20 mm Hg indicates increased intracranial
pressure, which is a medical emergency requiring immediate provider
intervention to prevent brain herniation. While oxygen administration
may be appropriate, notification is the priority to obtain orders for
interventions such as mannitol or hyperventilation .
Question 2: A nurse is assessing a client with a head injury. Which
assessment finding indicates a worsening Glasgow Coma Scale (GCS)
score?
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A) Eye opening to verbal stimuli
B) No response to painful stimuli
C) Obeys verbal commands
D) Verbal response of oriented speech
Answer: B) No response to painful stimuli
Rationale: No response to painful stimuli indicates a severe decline in
neurological function and significantly lowers the GCS score. The GCS
assesses eye opening, verbal response, and motor response; absence of
response to pain is the lowest possible motor score .
Question 3: A client with a C5 spinal cord injury is at highest risk for
which complication?
A) Hyperglycemia
B) Respiratory failure
C) Hypokalemia
D) Hypertension
Answer: B) Respiratory failure
Rationale: A C5 spinal cord injury affects the phrenic nerve (C3-C5),
which innervates the diaphragm. This injury can impair diaphragmatic
function, leading to respiratory failure. These patients often require
mechanical ventilation .
Question 4: A client has a head injury and presents with signs of
increased intracranial pressure. Which nursing intervention would be
most helpful in reducing this pressure?
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A) Place the neck in a neutral position to promote venous drainage
B) Suction hourly to stimulate the cough reflex
C) Add extra blankets to keep the client warm
D) Turn the client frequently to prevent skin impairment
Answer: A) Place the neck in a neutral position to promote venous
drainage
Rationale: Maintaining the neck in a neutral position prevents jugular
vein compression, which facilitates venous drainage from the brain and
helps reduce ICP. Flexion or rotation of the neck can impede venous
outflow and increase ICP .
Question 5: Which assessment finding indicates increased intracranial
pressure (ICP)? Select all that apply.
A) Widened pulse pressure
B) Tachycardia
C) Irregular respirations
D) Hypertension
E) Hypothermia
Answers: A, C, D
Rationale: Cushing's triad—widened pulse pressure, bradycardia (not
tachycardia), and irregular respirations—is a late sign of increased ICP.
Hypertension is also commonly seen. Tachycardia and hypothermia are
not typical signs of elevated ICP .
Question 6: A client is being evaluated in the emergency department for
a possible head injury after an automobile accident. Which diagnostic
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test should NOT be performed if there is indication of increased
intracranial pressure?
A) CT scan
B) MRI scan
C) Lumbar puncture
D) Electroencephalogram
Answer: C) Lumbar puncture
Rationale: Lumbar puncture is contraindicated when increased ICP is
suspected because the sudden decrease in pressure below the level of the
obstruction can cause brain herniation through the foramen magnum .
Question 7: A client with a brain tumor reports a headache that is worse
in the morning. What is the likely cause?
A) Dehydration
B) Increased intracranial pressure
C) Hypoglycemia
D) Sinus congestion
Answer: B) Increased intracranial pressure
Rationale: Morning headaches in brain tumor patients are often due to
increased ICP from lying flat overnight. The supine position reduces
venous drainage, and CO2 retention during sleep can further elevate
ICP .
Question 8: A client with myasthenia gravis is experiencing muscle
weakness. What is the nurse's priority intervention?
NUR2755 Final Exam: Multidimensional Care IV
(MDC 4)
Latest 2026/2027 Edition | 100+ Practice Questions
with Verified Answers & Detailed Rationales
Section 1: Neurological Disorders (Questions 1-25)
Question 1: A client with a traumatic brain injury (TBI) has an
intracranial pressure (ICP) reading of 22 mm Hg. What is the nurse's
priority action?
A) Administer oxygen at 2 L/min via nasal cannula
B) Notify the healthcare provider immediately
C) Encourage deep breathing and coughing
D) Administer prescribed analgesics
Answer: B) Notify the healthcare provider immediately
Rationale: An ICP above 20 mm Hg indicates increased intracranial
pressure, which is a medical emergency requiring immediate provider
intervention to prevent brain herniation. While oxygen administration
may be appropriate, notification is the priority to obtain orders for
interventions such as mannitol or hyperventilation .
Question 2: A nurse is assessing a client with a head injury. Which
assessment finding indicates a worsening Glasgow Coma Scale (GCS)
score?
,2|Page
A) Eye opening to verbal stimuli
B) No response to painful stimuli
C) Obeys verbal commands
D) Verbal response of oriented speech
Answer: B) No response to painful stimuli
Rationale: No response to painful stimuli indicates a severe decline in
neurological function and significantly lowers the GCS score. The GCS
assesses eye opening, verbal response, and motor response; absence of
response to pain is the lowest possible motor score .
Question 3: A client with a C5 spinal cord injury is at highest risk for
which complication?
A) Hyperglycemia
B) Respiratory failure
C) Hypokalemia
D) Hypertension
Answer: B) Respiratory failure
Rationale: A C5 spinal cord injury affects the phrenic nerve (C3-C5),
which innervates the diaphragm. This injury can impair diaphragmatic
function, leading to respiratory failure. These patients often require
mechanical ventilation .
Question 4: A client has a head injury and presents with signs of
increased intracranial pressure. Which nursing intervention would be
most helpful in reducing this pressure?
,3|Page
A) Place the neck in a neutral position to promote venous drainage
B) Suction hourly to stimulate the cough reflex
C) Add extra blankets to keep the client warm
D) Turn the client frequently to prevent skin impairment
Answer: A) Place the neck in a neutral position to promote venous
drainage
Rationale: Maintaining the neck in a neutral position prevents jugular
vein compression, which facilitates venous drainage from the brain and
helps reduce ICP. Flexion or rotation of the neck can impede venous
outflow and increase ICP .
Question 5: Which assessment finding indicates increased intracranial
pressure (ICP)? Select all that apply.
A) Widened pulse pressure
B) Tachycardia
C) Irregular respirations
D) Hypertension
E) Hypothermia
Answers: A, C, D
Rationale: Cushing's triad—widened pulse pressure, bradycardia (not
tachycardia), and irregular respirations—is a late sign of increased ICP.
Hypertension is also commonly seen. Tachycardia and hypothermia are
not typical signs of elevated ICP .
Question 6: A client is being evaluated in the emergency department for
a possible head injury after an automobile accident. Which diagnostic
, 4|Page
test should NOT be performed if there is indication of increased
intracranial pressure?
A) CT scan
B) MRI scan
C) Lumbar puncture
D) Electroencephalogram
Answer: C) Lumbar puncture
Rationale: Lumbar puncture is contraindicated when increased ICP is
suspected because the sudden decrease in pressure below the level of the
obstruction can cause brain herniation through the foramen magnum .
Question 7: A client with a brain tumor reports a headache that is worse
in the morning. What is the likely cause?
A) Dehydration
B) Increased intracranial pressure
C) Hypoglycemia
D) Sinus congestion
Answer: B) Increased intracranial pressure
Rationale: Morning headaches in brain tumor patients are often due to
increased ICP from lying flat overnight. The supine position reduces
venous drainage, and CO2 retention during sleep can further elevate
ICP .
Question 8: A client with myasthenia gravis is experiencing muscle
weakness. What is the nurse's priority intervention?
