NUR 265 Exam 3 | 150 Questions and
Answers | Fall 2025/2026 Update |
100% Correct - Galen College of
Nursing
1. Which one of the following is a late sign of increased intracranial pressure
(ICP)?
A. Restlessness
B. Pupil dilation
C. Headache
D. Vomiting
Correct Answer-: B) Pupil dilation
Rationale: Pupil dilation (unilateral or bilateral) is a late sign of increased ICP
indicating brainstem compression and herniation. Earlier signs include
restlessness, headache, and vomiting as the brain compensates.
2. Which one of the following is the priority nursing intervention for a patient
with Autonomic Dysreflexia?
A. Administer antihypertensive medication
B. Place the patient in supine position
C. Elevate the head of the bed to 90 degrees
D. Notify the healthcare provider immediately
Correct Answer-: C) Elevate the head of the bed to 90 degrees
Rationale: The immediate priority in Autonomic Dysreflexia is to lower blood
pressure by elevating the head of the bed. This uses gravity to help pool blood in
the lower extremities. After this, the nurse should identify and remove the
noxious stimulus.
3. Which one of the following assessment findings confirms a cerebrospinal fluid
(CSF) leak in a patient with a basilar skull fracture?
A. Clear drainage from the ear
B. Bloody drainage from the nose
,C. Halo sign on linen
D. Ecchymosis behind the ear
Correct Answer-: C) Halo sign on linen
Rationale: The halo sign occurs when drainage from the nose or ear forms a
yellow or clear ring (halo) around a central spot of blood on gauze or linen. This
indicates the presence of CSF mixed with blood.
4. Which one of the following positions should be avoided in a patient with
increased ICP?
A. Head of bed elevated 30 degrees
B. Neutral head alignment
C. Hip flexion
D. Side-lying position
Correct Answer-: C) Hip flexion
Rationale: Hip flexion increases intra-abdominal and intrathoracic pressure,
which impedes venous return from the brain and can increase ICP. The head
should be elevated 30 degrees with neutral alignment to promote venous
drainage.
5. Which one of the following is the earliest indicator of neurologic
deterioration?
A. Change in pupil size
B. Change in level of consciousness
C. Change in motor response
D. Change in vital signs
Correct Answer-: B) Change in level of consciousness
Rationale: The most sensitive and earliest sign of declining neurologic status is a
change in level of consciousness, such as increasing lethargy, confusion, or
restlessness. Pupil changes and vital sign changes occur later.
6. Which one of the following describes decorticate posturing?
A. Extension and external rotation of arms and legs
B. Flexion of arms, wrists, and fingers with leg extension
C. Rigid extension of all extremities
D. Flaccid paralysis with no response
,Correct Answer-: B) Flexion of arms, wrists, and fingers with leg extension
Rationale: Decorticate (flexor) posturing involves flexion of the arms, wrists, and
fingers with extension of the legs. It indicates damage to the cerebral cortex or
corticospinal tracts above the brainstem.
7. Which one of the following is a key component of Cushing's triad?
A. Tachycardia
B. Hypotension
C. Narrowed pulse pressure
D. Bradycardia
Correct Answer-: D) Bradycardia
Rationale: Cushing's triad is a late sign of increased ICP consisting of hypertension
(with widening pulse pressure), bradycardia, and irregular respirations. It
indicates brainstem compression and is a medical emergency.
8. Which one of the following interventions helps prevent autcontamination in a
burn patient?
A. Wearing sterile gloves for wound care
B. Changing gloves between wound sites on the same patient
C. Using sterile drapes for all procedures
D. Placing the patient in a negative pressure room
Correct Answer-: B) Changing gloves between wound sites on the same
patient
Rationale: Autocontamination refers to spreading infection from one area of the
patient's own body to another. Changing gloves between wound sites prevents
this cross-contamination.
9. A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score
of 6. How should the nurse interpret this finding?
A. Mild brain injury
B. Moderate brain injury
C. Severe brain injury
D. No brain injury
, Correct Answer-: C) Severe brain injury
Rationale: GCS scores range from 3 to 15. A score of 8 or less indicates severe
brain injury, requiring immediate intervention and frequent reassessment.
10. What is the priority nursing intervention for a patient experiencing a tonic-
clonic seizure?
A. Restrain the patient to prevent injury
B. Place a tongue blade in the mouth to prevent aspiration
C. Position the patient on their side and protect the head
D. Administer oral antiepileptic medication immediately
Correct Answer-: C) Position the patient on their side and protect the head
Rationale: During a seizure, the priority is safety. The patient should be placed on
their side to prevent aspiration, and the head should be protected. Restraint and
oral objects are contraindicated.
11. Which medication is the first-line treatment for status epilepticus?
A. Lorazepam (Ativan)
B. Phenytoin (Dilantin)
C. Valproic acid (Depakote)
D. Levetiracetam (Keppra)
Correct Answer-: A) Lorazepam (Ativan)
Rationale: Benzodiazepines (lorazepam, diazepam) are the first-line treatment for
status epilepticus to rapidly terminate seizure activity.
12. A patient with a spinal cord injury at T6 develops sudden hypertension,
bradycardia, and severe headache. What is the most likely cause?
A. Spinal shock
B. Autonomic dysreflexia
C. Neurogenic shock
D. Pulmonary embolism
Correct Answer-: B) Autonomic dysreflexia
Rationale: Autonomic dysreflexia occurs in spinal cord injuries above T6. A
noxious stimulus below the injury level triggers an exaggerated sympathetic
response, causing hypertension, bradycardia, and headache.
Answers | Fall 2025/2026 Update |
100% Correct - Galen College of
Nursing
1. Which one of the following is a late sign of increased intracranial pressure
(ICP)?
A. Restlessness
B. Pupil dilation
C. Headache
D. Vomiting
Correct Answer-: B) Pupil dilation
Rationale: Pupil dilation (unilateral or bilateral) is a late sign of increased ICP
indicating brainstem compression and herniation. Earlier signs include
restlessness, headache, and vomiting as the brain compensates.
2. Which one of the following is the priority nursing intervention for a patient
with Autonomic Dysreflexia?
A. Administer antihypertensive medication
B. Place the patient in supine position
C. Elevate the head of the bed to 90 degrees
D. Notify the healthcare provider immediately
Correct Answer-: C) Elevate the head of the bed to 90 degrees
Rationale: The immediate priority in Autonomic Dysreflexia is to lower blood
pressure by elevating the head of the bed. This uses gravity to help pool blood in
the lower extremities. After this, the nurse should identify and remove the
noxious stimulus.
3. Which one of the following assessment findings confirms a cerebrospinal fluid
(CSF) leak in a patient with a basilar skull fracture?
A. Clear drainage from the ear
B. Bloody drainage from the nose
,C. Halo sign on linen
D. Ecchymosis behind the ear
Correct Answer-: C) Halo sign on linen
Rationale: The halo sign occurs when drainage from the nose or ear forms a
yellow or clear ring (halo) around a central spot of blood on gauze or linen. This
indicates the presence of CSF mixed with blood.
4. Which one of the following positions should be avoided in a patient with
increased ICP?
A. Head of bed elevated 30 degrees
B. Neutral head alignment
C. Hip flexion
D. Side-lying position
Correct Answer-: C) Hip flexion
Rationale: Hip flexion increases intra-abdominal and intrathoracic pressure,
which impedes venous return from the brain and can increase ICP. The head
should be elevated 30 degrees with neutral alignment to promote venous
drainage.
5. Which one of the following is the earliest indicator of neurologic
deterioration?
A. Change in pupil size
B. Change in level of consciousness
C. Change in motor response
D. Change in vital signs
Correct Answer-: B) Change in level of consciousness
Rationale: The most sensitive and earliest sign of declining neurologic status is a
change in level of consciousness, such as increasing lethargy, confusion, or
restlessness. Pupil changes and vital sign changes occur later.
6. Which one of the following describes decorticate posturing?
A. Extension and external rotation of arms and legs
B. Flexion of arms, wrists, and fingers with leg extension
C. Rigid extension of all extremities
D. Flaccid paralysis with no response
,Correct Answer-: B) Flexion of arms, wrists, and fingers with leg extension
Rationale: Decorticate (flexor) posturing involves flexion of the arms, wrists, and
fingers with extension of the legs. It indicates damage to the cerebral cortex or
corticospinal tracts above the brainstem.
7. Which one of the following is a key component of Cushing's triad?
A. Tachycardia
B. Hypotension
C. Narrowed pulse pressure
D. Bradycardia
Correct Answer-: D) Bradycardia
Rationale: Cushing's triad is a late sign of increased ICP consisting of hypertension
(with widening pulse pressure), bradycardia, and irregular respirations. It
indicates brainstem compression and is a medical emergency.
8. Which one of the following interventions helps prevent autcontamination in a
burn patient?
A. Wearing sterile gloves for wound care
B. Changing gloves between wound sites on the same patient
C. Using sterile drapes for all procedures
D. Placing the patient in a negative pressure room
Correct Answer-: B) Changing gloves between wound sites on the same
patient
Rationale: Autocontamination refers to spreading infection from one area of the
patient's own body to another. Changing gloves between wound sites prevents
this cross-contamination.
9. A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score
of 6. How should the nurse interpret this finding?
A. Mild brain injury
B. Moderate brain injury
C. Severe brain injury
D. No brain injury
, Correct Answer-: C) Severe brain injury
Rationale: GCS scores range from 3 to 15. A score of 8 or less indicates severe
brain injury, requiring immediate intervention and frequent reassessment.
10. What is the priority nursing intervention for a patient experiencing a tonic-
clonic seizure?
A. Restrain the patient to prevent injury
B. Place a tongue blade in the mouth to prevent aspiration
C. Position the patient on their side and protect the head
D. Administer oral antiepileptic medication immediately
Correct Answer-: C) Position the patient on their side and protect the head
Rationale: During a seizure, the priority is safety. The patient should be placed on
their side to prevent aspiration, and the head should be protected. Restraint and
oral objects are contraindicated.
11. Which medication is the first-line treatment for status epilepticus?
A. Lorazepam (Ativan)
B. Phenytoin (Dilantin)
C. Valproic acid (Depakote)
D. Levetiracetam (Keppra)
Correct Answer-: A) Lorazepam (Ativan)
Rationale: Benzodiazepines (lorazepam, diazepam) are the first-line treatment for
status epilepticus to rapidly terminate seizure activity.
12. A patient with a spinal cord injury at T6 develops sudden hypertension,
bradycardia, and severe headache. What is the most likely cause?
A. Spinal shock
B. Autonomic dysreflexia
C. Neurogenic shock
D. Pulmonary embolism
Correct Answer-: B) Autonomic dysreflexia
Rationale: Autonomic dysreflexia occurs in spinal cord injuries above T6. A
noxious stimulus below the injury level triggers an exaggerated sympathetic
response, causing hypertension, bradycardia, and headache.
