NUR 265 Exam 3 Medical-Surgical Nursing (2026) PDF |
Galen College of Nursing Graded A+(100 +QUESTIONS
WITH ANSWERS AND RATIONALES)
THIS EXAM INCLUDES:
• NUR 265 Exam 3
• Medical-Surgical Nursing (2026)
• Galen College of Nursing
• Graded A+
• 100+QUESTIONS
• ANSWERS WITH RATIONALES
, Traumatic Brain Injury (TBI) & Increased Intracranial Pressure (ICP)
This section covers the highest-priority concepts for Exam 3, including assessment
of neurological decline and emergency interventions.
Question 1: The nurse is caring for an adult client who was recently admitted with
a head injury following a motor vehicle crash. One hour ago, the client's vital signs
(VS) were T: 98.6°F; P: 110; R: 26; BP: 128/68 mm Hg. Which of the following
findings is a priority for the nurse to follow up?
A) P: 90; R: 32; BP: 130/72 mm Hg
B) P: 120; R: 26, BP: 110/70 mm Hg
C) P: 56; R: 14; BP: 166/52 mm Hg
D) P: 64, R: 30; BP: 148/78m Hg
Correct Answer: C
Rationale: The combination of bradycardia (P: 56) , hypertension (BP: 166/52) ,
and irregular respirations is Cushing's Triad, a late and ominous sign of
significantly increased intracranial pressure (ICP) and impending brain herniation.
This is a medical emergency requiring immediate intervention.
Question 2: The nurse is caring for a client who sustained a closed head injury, is
receiving mechanical ventilation, and is at risk for developing increased ICP. Which
of the following actions should the nurse take when caring for this client?
A) Perform passive range of motion (ROM) to the client's hips and knees.
B) Log roll the client during turning and repositioning.
C) Elevate the foot of the client's bed.
D) Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
Correct Answer: B
Rationale: Maintaining spinal alignment is critical after a head injury. The client
should be log-rolled (turned as a unit with the head, neck, and spine aligned) to
prevent any twisting or flexion that could increase ICP or cause further spinal cord
injury.
,Question 3: The nurse is providing discharge instructions to the parents of a 15-
year-old female who sustained a concussion while playing field hockey. Which of
the following statements by a parent indicates a need for further teaching?
A) "We should avoid giving any acetaminophen to treat headaches."
B) "We need to bring our daughter back to the emergency department if she
exhibits blurred vision."
C) "We should provide a consistent routine at home to assist with any behavior
changes."
D) "We will not allow our daughter to engage in strenuous activity for at least 48
hours."
Correct Answer: A
Rationale: Acetaminophen (Tylenol) is the recommended analgesic for
headaches following a concussion because it does not increase the risk of
bleeding, unlike NSAIDs (ibuprofen, naproxen) or aspirin. Complete avoidance of
acetaminophen indicates a misunderstanding of discharge instructions.
Neurological Disorders (Meningitis, Myasthenia Gravis, Spinal Cord Injury)
This section focuses on recognizing critical symptoms and initiating priority
nursing actions for complex neuro conditions.
Question 4: The nurse working in the emergency department (ED) is admitting a
client who is a college student and lives in a dormitory. The client has chills, nuchal
rigidity, and a temperature (T) of 101.5° F. Which of the following actions should
the nurse take first?
A) Obtain a blood culture and start intravenous (IV) antibiotics
B) Administer antipyretics as prescribed
C) Initiate droplet isolation precautions
D) Measure the client's oxygen saturation
Correct Answer: C
Rationale: Bacterial meningitis is highly contagious and transmitted via respiratory
droplets. The priority action is to initiate droplet precautions immediately upon
, admission (before diagnostic confirmation) to protect staff, other patients, and
visitors. Antibiotics are started after diagnostic tests (LP, blood cultures) are
obtained.
Question 5: The nurse is caring for a client who has myasthenia gravis (MG). The
client reports increased muscle weakness and difficulty swallowing. Which of the
following actions should the nurse take first?
A) Administer the prescribed PRN laxative.
B) Assess the client's respiratory status and oxygen saturation.
C) Prepare to administer atropine sulfate.
D) Hold the next dose of pyridostigmine.
Correct Answer: B
Rationale: In a client with MG, worsening weakness and dysphagia signal a
potential myasthenic crisis. This can rapidly progress to respiratory failure. The
nurse's priority is to assess the airway and breathing (respiratory rate, oxygen
saturation, lung sounds) to determine the need for immediate respiratory
support.
Question 6: The nurse is caring for a client who has paraplegia and is being
transferred to a rehabilitation facility. The client suddenly becomes flushed,
reports a severe pounding headache, and has a blood pressure of 190/110 mm
Hg. Which of the following actions should the nurse take first?
A) Administer a prescribed PRN antihypertensive.
B) Check the client's indwelling urinary catheter for kinks or obstruction.
C) Elevate the head of the bed to a high Fowler's position.
D) Notify the primary health care provider (PHCP).
Correct Answer: B
Rationale: These are classic signs of autonomic dysreflexia, a life-threatening
emergency in clients with spinal cord injuries at T6 or above. The most common
cause is a distended bladder or bowel. The priority action is to identify and
remove the noxious stimulus—checking the catheter is the correct first step.
Raising the HOB is also critical but follows the initial assessment for the cause.
Galen College of Nursing Graded A+(100 +QUESTIONS
WITH ANSWERS AND RATIONALES)
THIS EXAM INCLUDES:
• NUR 265 Exam 3
• Medical-Surgical Nursing (2026)
• Galen College of Nursing
• Graded A+
• 100+QUESTIONS
• ANSWERS WITH RATIONALES
, Traumatic Brain Injury (TBI) & Increased Intracranial Pressure (ICP)
This section covers the highest-priority concepts for Exam 3, including assessment
of neurological decline and emergency interventions.
Question 1: The nurse is caring for an adult client who was recently admitted with
a head injury following a motor vehicle crash. One hour ago, the client's vital signs
(VS) were T: 98.6°F; P: 110; R: 26; BP: 128/68 mm Hg. Which of the following
findings is a priority for the nurse to follow up?
A) P: 90; R: 32; BP: 130/72 mm Hg
B) P: 120; R: 26, BP: 110/70 mm Hg
C) P: 56; R: 14; BP: 166/52 mm Hg
D) P: 64, R: 30; BP: 148/78m Hg
Correct Answer: C
Rationale: The combination of bradycardia (P: 56) , hypertension (BP: 166/52) ,
and irregular respirations is Cushing's Triad, a late and ominous sign of
significantly increased intracranial pressure (ICP) and impending brain herniation.
This is a medical emergency requiring immediate intervention.
Question 2: The nurse is caring for a client who sustained a closed head injury, is
receiving mechanical ventilation, and is at risk for developing increased ICP. Which
of the following actions should the nurse take when caring for this client?
A) Perform passive range of motion (ROM) to the client's hips and knees.
B) Log roll the client during turning and repositioning.
C) Elevate the foot of the client's bed.
D) Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
Correct Answer: B
Rationale: Maintaining spinal alignment is critical after a head injury. The client
should be log-rolled (turned as a unit with the head, neck, and spine aligned) to
prevent any twisting or flexion that could increase ICP or cause further spinal cord
injury.
,Question 3: The nurse is providing discharge instructions to the parents of a 15-
year-old female who sustained a concussion while playing field hockey. Which of
the following statements by a parent indicates a need for further teaching?
A) "We should avoid giving any acetaminophen to treat headaches."
B) "We need to bring our daughter back to the emergency department if she
exhibits blurred vision."
C) "We should provide a consistent routine at home to assist with any behavior
changes."
D) "We will not allow our daughter to engage in strenuous activity for at least 48
hours."
Correct Answer: A
Rationale: Acetaminophen (Tylenol) is the recommended analgesic for
headaches following a concussion because it does not increase the risk of
bleeding, unlike NSAIDs (ibuprofen, naproxen) or aspirin. Complete avoidance of
acetaminophen indicates a misunderstanding of discharge instructions.
Neurological Disorders (Meningitis, Myasthenia Gravis, Spinal Cord Injury)
This section focuses on recognizing critical symptoms and initiating priority
nursing actions for complex neuro conditions.
Question 4: The nurse working in the emergency department (ED) is admitting a
client who is a college student and lives in a dormitory. The client has chills, nuchal
rigidity, and a temperature (T) of 101.5° F. Which of the following actions should
the nurse take first?
A) Obtain a blood culture and start intravenous (IV) antibiotics
B) Administer antipyretics as prescribed
C) Initiate droplet isolation precautions
D) Measure the client's oxygen saturation
Correct Answer: C
Rationale: Bacterial meningitis is highly contagious and transmitted via respiratory
droplets. The priority action is to initiate droplet precautions immediately upon
, admission (before diagnostic confirmation) to protect staff, other patients, and
visitors. Antibiotics are started after diagnostic tests (LP, blood cultures) are
obtained.
Question 5: The nurse is caring for a client who has myasthenia gravis (MG). The
client reports increased muscle weakness and difficulty swallowing. Which of the
following actions should the nurse take first?
A) Administer the prescribed PRN laxative.
B) Assess the client's respiratory status and oxygen saturation.
C) Prepare to administer atropine sulfate.
D) Hold the next dose of pyridostigmine.
Correct Answer: B
Rationale: In a client with MG, worsening weakness and dysphagia signal a
potential myasthenic crisis. This can rapidly progress to respiratory failure. The
nurse's priority is to assess the airway and breathing (respiratory rate, oxygen
saturation, lung sounds) to determine the need for immediate respiratory
support.
Question 6: The nurse is caring for a client who has paraplegia and is being
transferred to a rehabilitation facility. The client suddenly becomes flushed,
reports a severe pounding headache, and has a blood pressure of 190/110 mm
Hg. Which of the following actions should the nurse take first?
A) Administer a prescribed PRN antihypertensive.
B) Check the client's indwelling urinary catheter for kinks or obstruction.
C) Elevate the head of the bed to a high Fowler's position.
D) Notify the primary health care provider (PHCP).
Correct Answer: B
Rationale: These are classic signs of autonomic dysreflexia, a life-threatening
emergency in clients with spinal cord injuries at T6 or above. The most common
cause is a distended bladder or bowel. The priority action is to identify and
remove the noxious stimulus—checking the catheter is the correct first step.
Raising the HOB is also critical but follows the initial assessment for the cause.
