NUR 265 Exam 3 | Questions and
Answers | 2026 Update | 100% Correct –
Galen College Neurologic Emergencies &
Traumatic Brain Injury
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1. A nurse is caring for a patient with a traumatic brain injury (TBI).
Which finding should the nurse recognize as the earliest sign of
neurologic deterioration?**
A. Fixed and dilated pupils
B. Decerebrate posturing
C. Decreased level of consciousness (LOC)
D. Cushing's triad
**Answer:** C. Decreased level of consciousness (LOC)
**Rationale:** A change in LOC is the most sensitive and earliest
indicator of neurologic deterioration and increased intracranial
pressure (ICP). It often manifests as restlessness, confusion, or
drowsiness before more obvious signs appear .
**2. A patient has a Glasgow Coma Scale (GCS) score of 6. How should
the nurse interpret this finding?**
A. Mild neurologic impairment
,B. Moderate neurologic impairment
C. Patient is comatose
D. Normal neurologic status
**Answer:** C. Patient is comatose
**Rationale:** A GCS score of 8 or less indicates a severe TBI and coma.
A score of 3-8 is classified as severe, 9-12 as moderate, and 13-15 as
mild .
**3. The nurse observes a patient with a brain injury extending their
arms, stiffening them, and pushing them away from the body with
palms turned outward. How should this finding be documented?**
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid paralysis
D. Hemiparesis
**Answer:** B. Decerebrate posturing
**Rationale:** Decerebrate (extensor) posturing is characterized by
rigid extension and adduction of the arms, with internal rotation and
plantar flexion of the feet. It indicates severe brain stem damage and is
a poorer prognostic sign than decorticate posturing .
**4. Which assessment finding is associated with Cushing's triad, a late
sign of increased ICP?**
A. Tachycardia and hypotension
,B. Widened pulse pressure and bradycardia
C. Fever and tachypnea
D. Narrowed pulse pressure and tachycardia
**Answer:** B. Widened pulse pressure and bradycardia
**Rationale:** Cushing's triad is a late and ominous sign of severely
increased ICP. It consists of severe hypertension with a widened pulse
pressure, bradycardia, and irregular respirations .
**5. The nurse is caring for a trauma patient with suspected TBI. What
is the priority nursing action?**
A. Obtain a CT scan
B. Assess neurologic status
C. Assess airway, breathing, and circulation (ABCs)
D. Check pupillary response
**Answer:** C. Assess airway, breathing, and circulation (ABCs)
**Rationale:** The primary survey in any trauma patient follows the
ABCs. Ensuring a patent airway and adequate oxygenation and
circulation is the priority before proceeding with a detailed neurologic
assessment or diagnostic imaging .
**6. A patient with a basilar skull fracture is suspected of having a CSF
leak. Which assessment finding supports this suspicion?**
A. Bloody drainage from the ear
B. Halo sign on an absorbent pad
, C. Yellow nasal mucus
D. Clear sputum
**Answer:** B. Halo sign on an absorbent pad
**Rationale:** A CSF leak can be identified by the "halo sign" or "target
sign," where drainage on a white absorbent pad forms a central bloody
spot surrounded by a clear or yellowish ring .
**7. A patient with a moderate-to-severe TBI is at risk for secondary
brain injury. Which of the following is the most common cause of
secondary injury?**
A. Hypernatremia
B. Hypotension and hypoxia
C. Hyperventilation
D. Hypoglycemia
**Answer:** B. Hypotension and hypoxia
**Rationale:** Secondary brain injury results from the brain's response
to the initial trauma. The most common causes are hypotension (MAP
<70 mmHg) and hypoxia (PaO2 <80 mmHg), which further compromise
cerebral perfusion and oxygenation .
**8. A normal level of intracranial pressure (ICP) is ____ to ____
mmHg.**
A. 0 to 5
B. 5 to 10
Answers | 2026 Update | 100% Correct –
Galen College Neurologic Emergencies &
Traumatic Brain Injury
---
1. A nurse is caring for a patient with a traumatic brain injury (TBI).
Which finding should the nurse recognize as the earliest sign of
neurologic deterioration?**
A. Fixed and dilated pupils
B. Decerebrate posturing
C. Decreased level of consciousness (LOC)
D. Cushing's triad
**Answer:** C. Decreased level of consciousness (LOC)
**Rationale:** A change in LOC is the most sensitive and earliest
indicator of neurologic deterioration and increased intracranial
pressure (ICP). It often manifests as restlessness, confusion, or
drowsiness before more obvious signs appear .
**2. A patient has a Glasgow Coma Scale (GCS) score of 6. How should
the nurse interpret this finding?**
A. Mild neurologic impairment
,B. Moderate neurologic impairment
C. Patient is comatose
D. Normal neurologic status
**Answer:** C. Patient is comatose
**Rationale:** A GCS score of 8 or less indicates a severe TBI and coma.
A score of 3-8 is classified as severe, 9-12 as moderate, and 13-15 as
mild .
**3. The nurse observes a patient with a brain injury extending their
arms, stiffening them, and pushing them away from the body with
palms turned outward. How should this finding be documented?**
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid paralysis
D. Hemiparesis
**Answer:** B. Decerebrate posturing
**Rationale:** Decerebrate (extensor) posturing is characterized by
rigid extension and adduction of the arms, with internal rotation and
plantar flexion of the feet. It indicates severe brain stem damage and is
a poorer prognostic sign than decorticate posturing .
**4. Which assessment finding is associated with Cushing's triad, a late
sign of increased ICP?**
A. Tachycardia and hypotension
,B. Widened pulse pressure and bradycardia
C. Fever and tachypnea
D. Narrowed pulse pressure and tachycardia
**Answer:** B. Widened pulse pressure and bradycardia
**Rationale:** Cushing's triad is a late and ominous sign of severely
increased ICP. It consists of severe hypertension with a widened pulse
pressure, bradycardia, and irregular respirations .
**5. The nurse is caring for a trauma patient with suspected TBI. What
is the priority nursing action?**
A. Obtain a CT scan
B. Assess neurologic status
C. Assess airway, breathing, and circulation (ABCs)
D. Check pupillary response
**Answer:** C. Assess airway, breathing, and circulation (ABCs)
**Rationale:** The primary survey in any trauma patient follows the
ABCs. Ensuring a patent airway and adequate oxygenation and
circulation is the priority before proceeding with a detailed neurologic
assessment or diagnostic imaging .
**6. A patient with a basilar skull fracture is suspected of having a CSF
leak. Which assessment finding supports this suspicion?**
A. Bloody drainage from the ear
B. Halo sign on an absorbent pad
, C. Yellow nasal mucus
D. Clear sputum
**Answer:** B. Halo sign on an absorbent pad
**Rationale:** A CSF leak can be identified by the "halo sign" or "target
sign," where drainage on a white absorbent pad forms a central bloody
spot surrounded by a clear or yellowish ring .
**7. A patient with a moderate-to-severe TBI is at risk for secondary
brain injury. Which of the following is the most common cause of
secondary injury?**
A. Hypernatremia
B. Hypotension and hypoxia
C. Hyperventilation
D. Hypoglycemia
**Answer:** B. Hypotension and hypoxia
**Rationale:** Secondary brain injury results from the brain's response
to the initial trauma. The most common causes are hypotension (MAP
<70 mmHg) and hypoxia (PaO2 <80 mmHg), which further compromise
cerebral perfusion and oxygenation .
**8. A normal level of intracranial pressure (ICP) is ____ to ____
mmHg.**
A. 0 to 5
B. 5 to 10
