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1. A nurse is receiving a transfer report for a client who D. The client opens his
has a head injury. The client has a Glasgow Coma Scale eyes when spoken to
(GCS) score of 3 for eye opening, 5 for best verbal
response, and 5 for best motor response. Which of the A GCS of 3-5-5 indi-
following is an appropriate conclusion based on this cates that the client opens
data? his eyes in response to
speech, is orientated, and
A. The client can follow simple motor commands is able to localize pain
B. The client is unable to make vocal sound
C. The client is unconscious
D. The client opens his eyes when spoken to
2. A nurse is caring for a client who has increased in- C. Elevate the head of the
tracranial pressure. Which of the following nursing in- bed 30 degrees
terventions should the nurse take?
The nurse should elevate
A. Instruct the client to perform controlled coughing the head of the bed 15 de-
and deep breathing grees to 30 degrees to re-
B. Provide a brightly lit environment duce intracranial pressure
C. Elevate the head of the bed 30 degrees
D. Encourage a minimum intake of 2,000 mL/day of
clear fluids
3. A nurse is caring for a client following a lumbar punc- A. Provide oral fluids
ture. Which of the following actions should the nurse B. Monitor for nausea
take? D. Check level of con-
sciousness
A. Provide oral fluids E. Check sensation in the
B. Monitor for nausea toes
C. Maintain fetal position
D. Check level of consciousness
E. Check sensation in the toes
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4. A nurse is assisting in the planning of preventative care D. Reduce stimuli
for a client who is restless following a traumatic brain
injury with increased intracranial pressure. Which of
the following is an appropriate nursing action?
A. Apply restraints
B. Administer opioids
C. Blacken the room
D. Reduce stimuli
5. An acute care nurse is caring for an adult client who D. Level of consciousness
is undergoing evaluation for a possible brain tumor.
While performing a neurological examination, which
of the following findings is the earliest indicator of the
client's cerebral status?
A. Pupil response
B. Deep tendon reflexes
C. Muscle strength
D. Level of consciousness
6. A nurse is collecting data from a client who has a A. The client requires total
score of 8 using the Glasgow Coma Scale. Which of the nursing care
following findings should the nurse expect?
A. The client requires total nursing care
B. The client is alert and orientated
C. The client is in a deep coma
D. The client has a stable neurological status
7. A nurse is collecting data from a client who has in- C. Plantar flexion of the
creased intracranial pressure and is informed by the legs
charge nurse that the client demonstrated decorticate
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posturing. Which of the following findings should the
nurse expect to observe?
A. Extension of the extremities
B. Pronation of the hands
C. Plantar flexion of the legs
D. External rotation of the lower extremities
8. A nurse is assisting with caring for a client who has a D. Lethargy
new concussion following a motor vehicle crash. The
nurse should monitor the client for which of the follow-
ing manifestations of increased intracranial pressure?
A. Polyuria
B. Battle's sign
C. Nuchal rigidity
D. Lethargy
9. A nurse is collecting data from an infant who hit her B. Irritability
head when she fell off of a dressing table. The nurse
should identify which of the following findings as indi-
cating increased intracranial pressure?
A. Brisk pupillary reaction to light
B. Irritability
C. Tachycardia
D. Increased sensory response to painful stimuli
10. A nurse is contributing to the plan of care for a client D. Encourage oral fluids
following a lumbar puncture. Which of the following
interventions should the nurse include?
A. Provide the client a low-sodium diet
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B. Change the client's dressing every 12 hours
C. Place the client in high-Fowler's position
D. Encourage oral fluids
11. A nurse is caring for a client at risk for increased in- B. Checking pupillary re-
tracranial pressure is monitoring the client for mani- sponses to light
festations that indicate that the pressure is increasing.
To do this, The nurse should check the function of the
third cranial nerve by performing which of the follow-
ing data-collection activities?
A. Observing for facial asymmetry
B. Checking pupillary responses to light
C. Eliciting the gag reflex
D. Testing visual acuity
12. A nurse is assisting with the care of a client immedi- A. Encourage fluid intake
ately following a lumbar puncture. Which of following B. Monitor the puncture
actions should the nurse take? site for a hematoma
A. Encourage fluid intake
B. Monitor the puncture site for hematoma
C. Insert a urinary catheter
D. Elevate the client's head of bed
E. Apply a cervical collar to the client
13. A nurse is contributing to the plan of care for a client B. Elevate the head of the
who has increased intracranial pressure following a bed
closed-head injury. Which of the following interven-
tions should the nurse recommend?
A. Have the client perform huff coughing hourly
B. Elevate the head of the bed
Page 4 of 38 NUR 1700 Q5 Randoms.pdf 2026-04-11
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1. A nurse is receiving a transfer report for a client who D. The client opens his
has a head injury. The client has a Glasgow Coma Scale eyes when spoken to
(GCS) score of 3 for eye opening, 5 for best verbal
response, and 5 for best motor response. Which of the A GCS of 3-5-5 indi-
following is an appropriate conclusion based on this cates that the client opens
data? his eyes in response to
speech, is orientated, and
A. The client can follow simple motor commands is able to localize pain
B. The client is unable to make vocal sound
C. The client is unconscious
D. The client opens his eyes when spoken to
2. A nurse is caring for a client who has increased in- C. Elevate the head of the
tracranial pressure. Which of the following nursing in- bed 30 degrees
terventions should the nurse take?
The nurse should elevate
A. Instruct the client to perform controlled coughing the head of the bed 15 de-
and deep breathing grees to 30 degrees to re-
B. Provide a brightly lit environment duce intracranial pressure
C. Elevate the head of the bed 30 degrees
D. Encourage a minimum intake of 2,000 mL/day of
clear fluids
3. A nurse is caring for a client following a lumbar punc- A. Provide oral fluids
ture. Which of the following actions should the nurse B. Monitor for nausea
take? D. Check level of con-
sciousness
A. Provide oral fluids E. Check sensation in the
B. Monitor for nausea toes
C. Maintain fetal position
D. Check level of consciousness
E. Check sensation in the toes
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4. A nurse is assisting in the planning of preventative care D. Reduce stimuli
for a client who is restless following a traumatic brain
injury with increased intracranial pressure. Which of
the following is an appropriate nursing action?
A. Apply restraints
B. Administer opioids
C. Blacken the room
D. Reduce stimuli
5. An acute care nurse is caring for an adult client who D. Level of consciousness
is undergoing evaluation for a possible brain tumor.
While performing a neurological examination, which
of the following findings is the earliest indicator of the
client's cerebral status?
A. Pupil response
B. Deep tendon reflexes
C. Muscle strength
D. Level of consciousness
6. A nurse is collecting data from a client who has a A. The client requires total
score of 8 using the Glasgow Coma Scale. Which of the nursing care
following findings should the nurse expect?
A. The client requires total nursing care
B. The client is alert and orientated
C. The client is in a deep coma
D. The client has a stable neurological status
7. A nurse is collecting data from a client who has in- C. Plantar flexion of the
creased intracranial pressure and is informed by the legs
charge nurse that the client demonstrated decorticate
Page 2 of 38 NUR 1700 Q5 Randoms.pdf 2026-04-11
, NUR 1700 Q5 Randoms Page 3 3
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posturing. Which of the following findings should the
nurse expect to observe?
A. Extension of the extremities
B. Pronation of the hands
C. Plantar flexion of the legs
D. External rotation of the lower extremities
8. A nurse is assisting with caring for a client who has a D. Lethargy
new concussion following a motor vehicle crash. The
nurse should monitor the client for which of the follow-
ing manifestations of increased intracranial pressure?
A. Polyuria
B. Battle's sign
C. Nuchal rigidity
D. Lethargy
9. A nurse is collecting data from an infant who hit her B. Irritability
head when she fell off of a dressing table. The nurse
should identify which of the following findings as indi-
cating increased intracranial pressure?
A. Brisk pupillary reaction to light
B. Irritability
C. Tachycardia
D. Increased sensory response to painful stimuli
10. A nurse is contributing to the plan of care for a client D. Encourage oral fluids
following a lumbar puncture. Which of the following
interventions should the nurse include?
A. Provide the client a low-sodium diet
Page 3 of 38 NUR 1700 Q5 Randoms.pdf 2026-04-11
, NUR 1700 Q5 Randoms Page 4 4
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B. Change the client's dressing every 12 hours
C. Place the client in high-Fowler's position
D. Encourage oral fluids
11. A nurse is caring for a client at risk for increased in- B. Checking pupillary re-
tracranial pressure is monitoring the client for mani- sponses to light
festations that indicate that the pressure is increasing.
To do this, The nurse should check the function of the
third cranial nerve by performing which of the follow-
ing data-collection activities?
A. Observing for facial asymmetry
B. Checking pupillary responses to light
C. Eliciting the gag reflex
D. Testing visual acuity
12. A nurse is assisting with the care of a client immedi- A. Encourage fluid intake
ately following a lumbar puncture. Which of following B. Monitor the puncture
actions should the nurse take? site for a hematoma
A. Encourage fluid intake
B. Monitor the puncture site for hematoma
C. Insert a urinary catheter
D. Elevate the client's head of bed
E. Apply a cervical collar to the client
13. A nurse is contributing to the plan of care for a client B. Elevate the head of the
who has increased intracranial pressure following a bed
closed-head injury. Which of the following interven-
tions should the nurse recommend?
A. Have the client perform huff coughing hourly
B. Elevate the head of the bed
Page 4 of 38 NUR 1700 Q5 Randoms.pdf 2026-04-11
