NUR 265 EXAM 3
MEDICAL-SURGICAL NURSING Galen College of
Nursing
61 Questions with Verified Answers & Rationales
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
,Topic 1: Traumatic Brain Injury (TBI) & Increased
Intracranial Pressure (ICP)
(Questions 1–18)
1. The nurse is caring for an adult client admitted with a head injury following a
motor vehicle crash. One hour ago, vital signs were: T 98.6°F, P 110, R 26, BP
128/68. Current vital signs are: P 56, R 14, BP 166/52. Which finding is the
priority for the nurse to follow up?
A. Pulse 56 bpm
B. Respirations 14 per minute
C. Blood pressure 166/52 mm Hg
D. Temperature 98.6°F
Correct Answer: A – Pulse 56 bpm
Rationale: Bradycardia combined with hypertension and irregular respirations
indicates Cushing's triad, a classic sign of increased intracranial pressure (ICP) and
impending brain herniation. The decrease in pulse rate from 110 to 56 bpm with
rising BP is an ominous neurological sign requiring immediate attention.
2. The nurse is caring for a client with a closed head injury receiving mechanical
ventilation who is at risk for increased ICP. Which action requires intervention
by the charge nurse?
A. Log rolling the client during turning and repositioning
B. Performing frequent head and neck flexion exercises
C. Clustering care activities to minimize disturbance
D. Keeping the client flat in bed to improve cerebral perfusion
Correct Answer: B – Performing frequent head and neck flexion exercises
Rationale: Head and neck flexion compresses jugular veins, reducing venous
drainage from the brain and increasing ICP. The head should remain in a midline,
neutral position. Clustering care should be avoided as it increases ICP.
, 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 action?
A. Instructing the client not to assist during positioning
B. Checking the client's vital signs every hour
C. Clustering client care activities
D. Encouraging visitors not to stimulate the client
Correct Answer: C – Clustering client care activities
Rationale: Clustering care (e.g., turning, suctioning, vital signs together) increases
ICP by causing multiple stimuli at once. Care should be spaced out to allow 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. 28-year-old professional athlete
B. 45-year-old construction worker
C. 75-year-old who lives alone and has macular degeneration
D. 19-year-old college student who rides a motorcycle
Correct Answer: C – 75-year-old who lives alone and has macular degeneration
Rationale: Older adults, especially those living alone with sensory deficits like
macular degeneration, have a high risk for falls, resulting in TBIs. Young adults may
engage in risk-taking behaviors, but older adults have the highest incidence of TBI
related to falls.
5. A client with a severe TBI has an ICP monitor in place. The nurse notes an ICP
of 22 mm Hg sustained for 10 minutes. What is the nurse's priority action?
A. Administer prescribed mannitol
B. Notify the healthcare provider immediately
C. Elevate the head of the bed to 90 degrees
D. Check the client's gag reflex
Correct Answer: B – Notify the healthcare provider immediately
MEDICAL-SURGICAL NURSING Galen College of
Nursing
61 Questions with Verified Answers & Rationales
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
,Topic 1: Traumatic Brain Injury (TBI) & Increased
Intracranial Pressure (ICP)
(Questions 1–18)
1. The nurse is caring for an adult client admitted with a head injury following a
motor vehicle crash. One hour ago, vital signs were: T 98.6°F, P 110, R 26, BP
128/68. Current vital signs are: P 56, R 14, BP 166/52. Which finding is the
priority for the nurse to follow up?
A. Pulse 56 bpm
B. Respirations 14 per minute
C. Blood pressure 166/52 mm Hg
D. Temperature 98.6°F
Correct Answer: A – Pulse 56 bpm
Rationale: Bradycardia combined with hypertension and irregular respirations
indicates Cushing's triad, a classic sign of increased intracranial pressure (ICP) and
impending brain herniation. The decrease in pulse rate from 110 to 56 bpm with
rising BP is an ominous neurological sign requiring immediate attention.
2. The nurse is caring for a client with a closed head injury receiving mechanical
ventilation who is at risk for increased ICP. Which action requires intervention
by the charge nurse?
A. Log rolling the client during turning and repositioning
B. Performing frequent head and neck flexion exercises
C. Clustering care activities to minimize disturbance
D. Keeping the client flat in bed to improve cerebral perfusion
Correct Answer: B – Performing frequent head and neck flexion exercises
Rationale: Head and neck flexion compresses jugular veins, reducing venous
drainage from the brain and increasing ICP. The head should remain in a midline,
neutral position. Clustering care should be avoided as it increases ICP.
, 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 action?
A. Instructing the client not to assist during positioning
B. Checking the client's vital signs every hour
C. Clustering client care activities
D. Encouraging visitors not to stimulate the client
Correct Answer: C – Clustering client care activities
Rationale: Clustering care (e.g., turning, suctioning, vital signs together) increases
ICP by causing multiple stimuli at once. Care should be spaced out to allow 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. 28-year-old professional athlete
B. 45-year-old construction worker
C. 75-year-old who lives alone and has macular degeneration
D. 19-year-old college student who rides a motorcycle
Correct Answer: C – 75-year-old who lives alone and has macular degeneration
Rationale: Older adults, especially those living alone with sensory deficits like
macular degeneration, have a high risk for falls, resulting in TBIs. Young adults may
engage in risk-taking behaviors, but older adults have the highest incidence of TBI
related to falls.
5. A client with a severe TBI has an ICP monitor in place. The nurse notes an ICP
of 22 mm Hg sustained for 10 minutes. What is the nurse's priority action?
A. Administer prescribed mannitol
B. Notify the healthcare provider immediately
C. Elevate the head of the bed to 90 degrees
D. Check the client's gag reflex
Correct Answer: B – Notify the healthcare provider immediately
