NUR 265 EXAM 3
MEDICAL SURGICAL NURSING
GALEN COLLEGE OF NURSING
QUESTIONS WITH COMPLETE SOLUTIONS
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
, Question Bank (150 Questions)
Unit 7: Neurological Disorders (TBI, ICP, Stroke, Seizures)
1. A client with a head injury has vital signs changing from P 110, BP 128/68 to
P 56, BP 166/52. Which finding is the priority for the nurse to follow up?
• A. Pulse 56 bpm
• B. Respirations 14/min
• C. Blood pressure 166/52
• Answer: A. Pulse 56 bpm
• Rationale: This combination of bradycardia, hypertension, and irregular respirations
is Cushing's Triad, a LATE sign of severely increased ICP and impending herniation.
The pulse change is the most ominous component of this triad .
2. Which client is at the GREATEST risk for sustaining a Traumatic Brain Injury
(TBI)?
• A. 20-year-old college football player
• B. 45-year-old construction worker
• C. 75-year-old with macular degeneration living alone
• Answer: C. 75-year-old with macular degeneration
• Rationale: Older adults (65+) have the highest incidence of TBI, primarily due to falls.
Visual deficits like macular degeneration significantly increase fall risk .
3. A nurse is assessing a client post-concussion. Which finding requires
immediate intervention?
• A. Mild headache
• B. Retrograde amnesia
• C. Irritability and restlessness
• Answer: C. Irritability and restlessness
• Rationale: A change in behavior, specifically increased irritability or restlessness, can
indicate rising ICP or neurological deterioration. It requires immediate reassessment .
4. The nurse suspects a CSF leak in a client with a basilar skull fracture. Which
assessment confirms this?
• A. Bloody drainage from the nose
• B. Ecchymosis behind the ear (Battle's sign)
• C. Clear drainage on linen forming a "halo" (yellow ring)
• Answer: C. Halo sign (yellow ring)
, • Rationale: The "Halo sign" occurs when CSF (glucose positive) separates from blood
on a dressing, forming a yellow ring around the blood. This confirms a CSF leak .
5. A client with a closed head injury has an ICP of 22 mm Hg. Which action
should the nurse take first?
• A. Administer mannitol
• B. Raise the head of the bed to 30 degrees
• C. Notify the provider
• Answer: B. Raise the head of the bed to 30 degrees
• Rationale: Normal ICP is 0-15 mm Hg. Elevating the HOB to 30 degrees promotes
venous drainage from the brain, which is the first-line nursing intervention to help
lower ICP .
6. Which positioning technique is contraindicated for a client with increased
ICP?
• A. Head of bed elevated 30 degrees
• B. Log rolling during turning
• C. Hip flexion
• Answer: C. Hip flexion
• Rationale: Hip flexion increases intra-abdominal and intrathoracic pressure, which
impedes venous return from the brain, thereby increasing ICP .
7. The nurse is providing discharge teaching for mild TBI. Which statement by
the client indicates a need for further teaching?
• A. "I will take ibuprofen for my headache."
• B. "I will avoid alcohol for the next 24 hours."
• C. "I will wake up every 2 hours tonight."
• Answer: A. "I will take ibuprofen for my headache."
• Rationale: Acetaminophen (Tylenol) is preferred post-TBI. NSAIDs (ibuprofen,
aspirin) increase the risk of bleeding and should be avoided .
8. A client with a brain injury has a GCS score of 4. The nurse understands this
indicates:
• A. Mild impairment
• B. Moderate impairment
• C. Severe impairment
• Answer: C. Severe impairment
• Rationale: A GCS of 8 or less indicates severe brain injury and coma. A score of 4
suggests deep coma with no eye opening, no verbal response, and abnormal motor
posturing .
MEDICAL SURGICAL NURSING
GALEN COLLEGE OF NURSING
QUESTIONS WITH COMPLETE SOLUTIONS
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
, Question Bank (150 Questions)
Unit 7: Neurological Disorders (TBI, ICP, Stroke, Seizures)
1. A client with a head injury has vital signs changing from P 110, BP 128/68 to
P 56, BP 166/52. Which finding is the priority for the nurse to follow up?
• A. Pulse 56 bpm
• B. Respirations 14/min
• C. Blood pressure 166/52
• Answer: A. Pulse 56 bpm
• Rationale: This combination of bradycardia, hypertension, and irregular respirations
is Cushing's Triad, a LATE sign of severely increased ICP and impending herniation.
The pulse change is the most ominous component of this triad .
2. Which client is at the GREATEST risk for sustaining a Traumatic Brain Injury
(TBI)?
• A. 20-year-old college football player
• B. 45-year-old construction worker
• C. 75-year-old with macular degeneration living alone
• Answer: C. 75-year-old with macular degeneration
• Rationale: Older adults (65+) have the highest incidence of TBI, primarily due to falls.
Visual deficits like macular degeneration significantly increase fall risk .
3. A nurse is assessing a client post-concussion. Which finding requires
immediate intervention?
• A. Mild headache
• B. Retrograde amnesia
• C. Irritability and restlessness
• Answer: C. Irritability and restlessness
• Rationale: A change in behavior, specifically increased irritability or restlessness, can
indicate rising ICP or neurological deterioration. It requires immediate reassessment .
4. The nurse suspects a CSF leak in a client with a basilar skull fracture. Which
assessment confirms this?
• A. Bloody drainage from the nose
• B. Ecchymosis behind the ear (Battle's sign)
• C. Clear drainage on linen forming a "halo" (yellow ring)
• Answer: C. Halo sign (yellow ring)
, • Rationale: The "Halo sign" occurs when CSF (glucose positive) separates from blood
on a dressing, forming a yellow ring around the blood. This confirms a CSF leak .
5. A client with a closed head injury has an ICP of 22 mm Hg. Which action
should the nurse take first?
• A. Administer mannitol
• B. Raise the head of the bed to 30 degrees
• C. Notify the provider
• Answer: B. Raise the head of the bed to 30 degrees
• Rationale: Normal ICP is 0-15 mm Hg. Elevating the HOB to 30 degrees promotes
venous drainage from the brain, which is the first-line nursing intervention to help
lower ICP .
6. Which positioning technique is contraindicated for a client with increased
ICP?
• A. Head of bed elevated 30 degrees
• B. Log rolling during turning
• C. Hip flexion
• Answer: C. Hip flexion
• Rationale: Hip flexion increases intra-abdominal and intrathoracic pressure, which
impedes venous return from the brain, thereby increasing ICP .
7. The nurse is providing discharge teaching for mild TBI. Which statement by
the client indicates a need for further teaching?
• A. "I will take ibuprofen for my headache."
• B. "I will avoid alcohol for the next 24 hours."
• C. "I will wake up every 2 hours tonight."
• Answer: A. "I will take ibuprofen for my headache."
• Rationale: Acetaminophen (Tylenol) is preferred post-TBI. NSAIDs (ibuprofen,
aspirin) increase the risk of bleeding and should be avoided .
8. A client with a brain injury has a GCS score of 4. The nurse understands this
indicates:
• A. Mild impairment
• B. Moderate impairment
• C. Severe impairment
• Answer: C. Severe impairment
• Rationale: A GCS of 8 or less indicates severe brain injury and coma. A score of 4
suggests deep coma with no eye opening, no verbal response, and abnormal motor
posturing .
