NUR 417 FINAL EXAM 2026-2027 ACTUAL
QUESTIONS AND CORRECT ANSWERS
GRADED A+
Family members ask the nurse about the purpose of the ventriculostomy system
being used for intracranial pressure monitoring for a patient. Which of the
following responses by the nurse is best?
a. "This type of monitoring system is complex and highly skilled staff are needed."
b. "The monitoring system helps show whether blood flow to the brain is
adequate."
c. "The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure."
d. "This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage."
ANS: B Short and simple explanations should be given to patients and family
members. The other explanations are either too complicated to be easily
understood or may increase the family member's anxiety.
The nurse is caring for a patient with a head injury and has admission vital signs of
blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute.
Which of these vital signs, if taken 1 hour after admission, will be of most concern
to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
,c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad and indicate that the intracranial pressure (ICP)
has increased, and brain herniation may be imminent unless immediate action is
taken to reduce ICP. The other vital signs may indicate the need for changes in
treatment, but they are not indicative of an immediately life-threatening process.
The nurse is assessing a patient who is unconscious and applies a painful stimulus
to the nail beds. The patient responds with internal rotation, adduction, and flexion
of the arms. Which of the following terms should the nurse use when documenting
the findings?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is
documented as decorticate posturing. Extension of the arms and legs is decerebrate
posturing. Because the flexion is generalized, it does not indicate localization of
pain or flexion withdrawal.
A nurse is providing care for an unconscious patient with a head injury prescribed
IV mannitol. Which of the following parameters is best for the nurse to monitor to
determine if the mannitol has been effective?
a. Hematocrit
,b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure
ANS: D
Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial
pressure. It may initially reduce hematocrit and increase blood pressure, but these
are not the best parameters for evaluation of the effectiveness of the drug. Oxygen
saturation will not directly improve as a result of mannitol administration.
A patient with a head injury opens his or her eyes to verbal stimulation, curses
when stimulated, and does not respond to a verbal command to move but attempts
to remove a painful stimulus. Which of the following Glasgow Coma Scale scores
should the nurse document?
a. 9
b. 15
c. 13
d. 3
ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for
best motor response
A patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion
related to cerebral tissue swelling. Which of the following nursing interventions
should be included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
, b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANS: A
The patient with increased intracranial pressure (ICP) should be maintained in the
head-up position to help reduce ICP. Flexion of the hips and knees increases
abdominal pressure, which increases ICP. Because the stimulation associated with
nursing interventions increases ICP, clustering interventions will progressively
elevate ICP. Coughing increases intrathoracic pressure and ICP
The nurse is caring for a patient with a head injury who has clear nasal drainage.
Which of the following actions should the nurse take?
a. Have the patient blow the nose.
b. Check the nasal drainage for glucose.
c. Assure the patient that rhinorrhea is normal after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity
ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and
cerebrospinal
fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid
leaking from
the nose will have normal nasal flora, so culture and sensitivity will not be useful.
Blowing
the nose is avoided to prevent CSF leakage.
QUESTIONS AND CORRECT ANSWERS
GRADED A+
Family members ask the nurse about the purpose of the ventriculostomy system
being used for intracranial pressure monitoring for a patient. Which of the
following responses by the nurse is best?
a. "This type of monitoring system is complex and highly skilled staff are needed."
b. "The monitoring system helps show whether blood flow to the brain is
adequate."
c. "The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure."
d. "This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage."
ANS: B Short and simple explanations should be given to patients and family
members. The other explanations are either too complicated to be easily
understood or may increase the family member's anxiety.
The nurse is caring for a patient with a head injury and has admission vital signs of
blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute.
Which of these vital signs, if taken 1 hour after admission, will be of most concern
to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
,c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad and indicate that the intracranial pressure (ICP)
has increased, and brain herniation may be imminent unless immediate action is
taken to reduce ICP. The other vital signs may indicate the need for changes in
treatment, but they are not indicative of an immediately life-threatening process.
The nurse is assessing a patient who is unconscious and applies a painful stimulus
to the nail beds. The patient responds with internal rotation, adduction, and flexion
of the arms. Which of the following terms should the nurse use when documenting
the findings?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is
documented as decorticate posturing. Extension of the arms and legs is decerebrate
posturing. Because the flexion is generalized, it does not indicate localization of
pain or flexion withdrawal.
A nurse is providing care for an unconscious patient with a head injury prescribed
IV mannitol. Which of the following parameters is best for the nurse to monitor to
determine if the mannitol has been effective?
a. Hematocrit
,b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure
ANS: D
Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial
pressure. It may initially reduce hematocrit and increase blood pressure, but these
are not the best parameters for evaluation of the effectiveness of the drug. Oxygen
saturation will not directly improve as a result of mannitol administration.
A patient with a head injury opens his or her eyes to verbal stimulation, curses
when stimulated, and does not respond to a verbal command to move but attempts
to remove a painful stimulus. Which of the following Glasgow Coma Scale scores
should the nurse document?
a. 9
b. 15
c. 13
d. 3
ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for
best motor response
A patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion
related to cerebral tissue swelling. Which of the following nursing interventions
should be included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
, b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANS: A
The patient with increased intracranial pressure (ICP) should be maintained in the
head-up position to help reduce ICP. Flexion of the hips and knees increases
abdominal pressure, which increases ICP. Because the stimulation associated with
nursing interventions increases ICP, clustering interventions will progressively
elevate ICP. Coughing increases intrathoracic pressure and ICP
The nurse is caring for a patient with a head injury who has clear nasal drainage.
Which of the following actions should the nurse take?
a. Have the patient blow the nose.
b. Check the nasal drainage for glucose.
c. Assure the patient that rhinorrhea is normal after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity
ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and
cerebrospinal
fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid
leaking from
the nose will have normal nasal flora, so culture and sensitivity will not be useful.
Blowing
the nose is avoided to prevent CSF leakage.
