NUR 265 Exam 3 | Questions and
Answers | 2026 Update | 100% Correct
– Galen College Neurologic
Emergencies & Traumatic Brain Injury
Neurologic Emergencies & Traumatic Brain Injury | Spinal Cord Injury | Stroke | Seizures | Increased Intracranial
Pressure | Autonomic Dysreflexia
Neurologic Emergencies & Traumatic Brain Injury (Questions 1–30)
1. The nurse in the emergency department 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) if the
client:
A) Has a Glasgow Coma Scale (GCS) score of 15
B) Is alert and oriented
C) Takes prescribed warfarin daily
D) Has a history of migraines
C) Takes prescribed warfarin daily
Rationale: Warfarin is an anticoagulant. In a patient with a TBI, this significantly
increases the risk of intracranial hemorrhage and hematoma formation. This
requires immediate provider notification for possible reversal agents and urgent
scanning.
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 increased intracranial pressure (ICP). Which action by the newly
hired nurse requires intervention?
A) Maintaining the head of the bed at 30 degrees
B) Keeping the head in a midline position
C) Raising the foot of the client's bed
,D) Avoiding clustering of care activities
C) Raising the foot of the client's bed
Rationale: To prevent increased ICP, the head of the bed should be elevated to 30
degrees, and the head should be kept in a midline, neutral position. Raising the
foot of the bed (Trendelenburg) increases intracranial pressure and is
contraindicated.
3. The newly hired nurse is caring for a client admitted 12 hours ago with a TBI
who is at risk for developing ICP. The nurse preceptor should intervene if the
newly hired nurse is observed doing which of the following?
A) Elevating the head of the bed to 30 degrees
B) Administering prescribed stool softeners
C) Clustering client care activities
D) Maintaining a quiet environment
C) Clustering client care activities
Rationale: Clustering activities such as turning, suctioning, and bathing causes
sustained elevation in ICP. Nursing care should be spaced out to allow the
patient's ICP to return to baseline between interventions.
4. The nurse is assessing clients for the risk of sustaining a TBI. Which client
should the nurse identify as being at greatest risk?
A) A 70-year-old woman who uses a walker
B) A 20-year-old college student who participates on the football team
C) A 45-year-old construction worker
D) A 6-month-old infant
B) A 20-year-old college student who participates on the football team
Rationale: Young adults, particularly those involved in contact sports or high-risk
activities, have a high incidence of TBI. Other at-risk groups include older adults
(falls) and infants (shaken baby syndrome).
5. What causes Autonomic Dysreflexia?
A) A noxious stimulus below the level of a spinal cord injury, usually at or above
T6
B) Hypotension following spinal shock
C) Inadequate fluid resuscitation
D) Use of alpha-adrenergic blockers
,A) A noxious stimulus below the level of a spinal cord injury, usually at or above
T6
Rationale: The stimulus triggers a massive sympathetic response, but due to the
spinal cord lesion, the compensatory parasympathetic response cannot descend
below the injury level.
6. What are some examples of triggers of autonomic dysreflexia? (Select all that
apply)
A) Full bladder
B) Fecal impaction
C) Tight clothing
D) Skin pressure or irritation
E) All of the above
E) All of the above
Rationale: Bladder distention is the most common cause. Fecal impaction is the
second most common. Other stimuli include restrictive clothing, pressure ulcers,
and any noxious stimulus below the injury level.
7. What are the signs and symptoms of Autonomic Dysreflexia?
A) Hypotension, bradycardia, and cool, clammy skin
B) Severe hypertension, pounding headache, flushed face, and bradycardia
C) Hypothermia, tachycardia, and dilated pupils
D) Seizures and loss of consciousness
B) Severe hypertension, pounding headache, flushed face, and bradycardia
Rationale: The unopposed sympathetic response causes severe hypertension,
severe headache, flushing above the lesion, and reflex bradycardia. This is a
medical emergency.
8. The nurse is caring for a patient with a spinal cord injury at T5. The patient
suddenly reports a pounding headache and is flushed. The nurse notes a blood
pressure of 210/110 mmHg. What is the nurse's priority action?
A) Administer antihypertensive medication
B) Place the patient in a supine position
C) Check for a distended bladder or fecal impaction
D) Notify the provider immediately
C) Check for a distended bladder or fecal impaction
, Rationale: Autonomic dysreflexia is a medical emergency. The priority is to
identify and remove the triggering stimulus (most commonly a full bladder). After
removing the stimulus, the blood pressure usually normalizes.
9. A patient with a severe TBI has an ICP reading of 28 mmHg and a mean
arterial pressure (MAP) of 80 mmHg. What is the cerebral perfusion pressure
(CPP)?
A) 52 mmHg
B) 60 mmHg
C) 108 mmHg
D) 28 mmHg
A) 52 mmHg
Rationale: CPP = MAP – ICP = 80 – 28 = 52 mmHg. Normal CPP is 60–100 mmHg;
values below 50 mmHg indicate cerebral ischemia.
10. The nurse is caring for a patient with an ICP monitor. Which finding should
be reported immediately?
A) ICP of 18 mmHg
B) ICP of 22 mmHg
C) ICP of 12 mmHg
D) ICP of 10 mmHg
B) ICP of 22 mmHg
Rationale: Normal ICP is 5–15 mmHg. Sustained ICP above 20 mmHg is considered
elevated and requires intervention to prevent brain herniation.
11. The nurse is assessing a patient with a head injury. Which finding is the
earliest sign of increased ICP?
A) Pupillary dilation
B) Decorticate posturing
C) Change in level of consciousness
D) Cheyne-Stokes respirations
C) Change in level of consciousness
Rationale: Altered level of consciousness is the earliest and most sensitive sign of
increased ICP. Pupillary changes and posturing occur later.
12. A patient with a TBI has a GCS score of 6. How should the nurse interpret
this finding?
Answers | 2026 Update | 100% Correct
– Galen College Neurologic
Emergencies & Traumatic Brain Injury
Neurologic Emergencies & Traumatic Brain Injury | Spinal Cord Injury | Stroke | Seizures | Increased Intracranial
Pressure | Autonomic Dysreflexia
Neurologic Emergencies & Traumatic Brain Injury (Questions 1–30)
1. The nurse in the emergency department 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) if the
client:
A) Has a Glasgow Coma Scale (GCS) score of 15
B) Is alert and oriented
C) Takes prescribed warfarin daily
D) Has a history of migraines
C) Takes prescribed warfarin daily
Rationale: Warfarin is an anticoagulant. In a patient with a TBI, this significantly
increases the risk of intracranial hemorrhage and hematoma formation. This
requires immediate provider notification for possible reversal agents and urgent
scanning.
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 increased intracranial pressure (ICP). Which action by the newly
hired nurse requires intervention?
A) Maintaining the head of the bed at 30 degrees
B) Keeping the head in a midline position
C) Raising the foot of the client's bed
,D) Avoiding clustering of care activities
C) Raising the foot of the client's bed
Rationale: To prevent increased ICP, the head of the bed should be elevated to 30
degrees, and the head should be kept in a midline, neutral position. Raising the
foot of the bed (Trendelenburg) increases intracranial pressure and is
contraindicated.
3. The newly hired nurse is caring for a client admitted 12 hours ago with a TBI
who is at risk for developing ICP. The nurse preceptor should intervene if the
newly hired nurse is observed doing which of the following?
A) Elevating the head of the bed to 30 degrees
B) Administering prescribed stool softeners
C) Clustering client care activities
D) Maintaining a quiet environment
C) Clustering client care activities
Rationale: Clustering activities such as turning, suctioning, and bathing causes
sustained elevation in ICP. Nursing care should be spaced out to allow the
patient's ICP to return to baseline between interventions.
4. The nurse is assessing clients for the risk of sustaining a TBI. Which client
should the nurse identify as being at greatest risk?
A) A 70-year-old woman who uses a walker
B) A 20-year-old college student who participates on the football team
C) A 45-year-old construction worker
D) A 6-month-old infant
B) A 20-year-old college student who participates on the football team
Rationale: Young adults, particularly those involved in contact sports or high-risk
activities, have a high incidence of TBI. Other at-risk groups include older adults
(falls) and infants (shaken baby syndrome).
5. What causes Autonomic Dysreflexia?
A) A noxious stimulus below the level of a spinal cord injury, usually at or above
T6
B) Hypotension following spinal shock
C) Inadequate fluid resuscitation
D) Use of alpha-adrenergic blockers
,A) A noxious stimulus below the level of a spinal cord injury, usually at or above
T6
Rationale: The stimulus triggers a massive sympathetic response, but due to the
spinal cord lesion, the compensatory parasympathetic response cannot descend
below the injury level.
6. What are some examples of triggers of autonomic dysreflexia? (Select all that
apply)
A) Full bladder
B) Fecal impaction
C) Tight clothing
D) Skin pressure or irritation
E) All of the above
E) All of the above
Rationale: Bladder distention is the most common cause. Fecal impaction is the
second most common. Other stimuli include restrictive clothing, pressure ulcers,
and any noxious stimulus below the injury level.
7. What are the signs and symptoms of Autonomic Dysreflexia?
A) Hypotension, bradycardia, and cool, clammy skin
B) Severe hypertension, pounding headache, flushed face, and bradycardia
C) Hypothermia, tachycardia, and dilated pupils
D) Seizures and loss of consciousness
B) Severe hypertension, pounding headache, flushed face, and bradycardia
Rationale: The unopposed sympathetic response causes severe hypertension,
severe headache, flushing above the lesion, and reflex bradycardia. This is a
medical emergency.
8. The nurse is caring for a patient with a spinal cord injury at T5. The patient
suddenly reports a pounding headache and is flushed. The nurse notes a blood
pressure of 210/110 mmHg. What is the nurse's priority action?
A) Administer antihypertensive medication
B) Place the patient in a supine position
C) Check for a distended bladder or fecal impaction
D) Notify the provider immediately
C) Check for a distended bladder or fecal impaction
, Rationale: Autonomic dysreflexia is a medical emergency. The priority is to
identify and remove the triggering stimulus (most commonly a full bladder). After
removing the stimulus, the blood pressure usually normalizes.
9. A patient with a severe TBI has an ICP reading of 28 mmHg and a mean
arterial pressure (MAP) of 80 mmHg. What is the cerebral perfusion pressure
(CPP)?
A) 52 mmHg
B) 60 mmHg
C) 108 mmHg
D) 28 mmHg
A) 52 mmHg
Rationale: CPP = MAP – ICP = 80 – 28 = 52 mmHg. Normal CPP is 60–100 mmHg;
values below 50 mmHg indicate cerebral ischemia.
10. The nurse is caring for a patient with an ICP monitor. Which finding should
be reported immediately?
A) ICP of 18 mmHg
B) ICP of 22 mmHg
C) ICP of 12 mmHg
D) ICP of 10 mmHg
B) ICP of 22 mmHg
Rationale: Normal ICP is 5–15 mmHg. Sustained ICP above 20 mmHg is considered
elevated and requires intervention to prevent brain herniation.
11. The nurse is assessing a patient with a head injury. Which finding is the
earliest sign of increased ICP?
A) Pupillary dilation
B) Decorticate posturing
C) Change in level of consciousness
D) Cheyne-Stokes respirations
C) Change in level of consciousness
Rationale: Altered level of consciousness is the earliest and most sensitive sign of
increased ICP. Pupillary changes and posturing occur later.
12. A patient with a TBI has a GCS score of 6. How should the nurse interpret
this finding?
