NUR 265 Exam 3 | Questions and
Answers | 2026 Update | 100% Correct –
Galen College.
1. A client is admitted to the emergency department (ED) following a
motor vehicle crash and has sustained a traumatic brain injury (TBI). The
nurse assesses the client and notes posturing characterized by rigid
extension of all four extremities, plantar flexion, and internal rotation of
the arms. The nurse correctly documents this as:
• A) Decerebrate posturing
• B) Decorticate posturing
• C) Flaccid posturing
• D) Opisthotonos
Correct ,,,,answer,,,: A
Rationale: Decerebrate posturing (extension of all extremities) indicates
severe damage at the level of the brainstem, below the red nucleus
(midbrain). It has a worse prognosis than decorticate posturing, which is
flexion of the upper extremities. This distinction is crucial in a TBI
assessment.
2. The nurse is caring for a client with severe traumatic brain injury.
Increased intracranial pressure (ICP) is suspected. Which cerebral
perfusion pressure (CPP) range would the nurse recognize as appropriate
for maintaining adequate brain perfusion?
, • A) 20 to 40 mmHg
• B) 30 to 50 mmHg
• C) 40 to 60 mmHg
• D) 60 to 100 mmHg
Correct ,,,,answer,,,: D
Rationale: CPP is calculated as MAP – ICP, with a normal range of 70–100
mmHg. A CPP below 50–60 mmHg is associated with cerebral ischemia
and poor neurological outcomes. Maintaining CPP above 60 mmHg is a
therapeutic goal in severe TBI.
3. A client with a TBI is being monitored for ICP. The ICP reading has been
22 mmHg for the last hour. Which finding would the nurse anticipate as an
early sign of deterioration?
• A) Widening pulse pressure
• B) Bradycardia and irregular respirations
• C) Ipsilateral pupil dilation (blown pupil)
• D) Decreasing level of consciousness
Correct ,,,,answer,,,: D
Rationale: A decreased level of consciousness (lethargy, confusion) is
often the earliest sign of rising ICP. Cushing's triad (hypertension,
bradycardia, irregular respirations) and pupillary changes occur later and
herald impending herniation. Early recognition is key.
,4. A client with a TBI is intubated and mechanically ventilated. The nurse
would anticipate which PaCO₂ range to help manage ICP?
• A) 20 to 25 mmHg (mild hyperventilation)
• B) 25 to 30 mmHg (mild hyperventilation)
• C) 35 to 45 mmHg (normocapnia)
• D) 45 to 50 mmHg (permissive hypercapnia)
Correct ,,,,answer,,,: C
Rationale: Maintaining PaCO₂ in the normal range (35–45 mmHg) is
recommended in TBI. Hyperventilation (PaCO₂ < 35 mmHg)
vasoconstricts cerebral vessels and lowers ICP but can cause cerebral
ischemia and is reserved for acute herniation crises.
5. A client has a sustained ICP of 28 mmHg. The nurse should position the
client with the head of the bed:
• A) Flat
• B) Elevated 15 to 30 degrees
• C) Elevated 45 to 60 degrees
• D) In a Trendelenburg position
Correct ,,,,answer,,,: B
Rationale: For ICP management, the head of the bed is
generally elevated to 30° (or 15–30°). This promotes venous drainage
from the head, reducing ICP. Flat or Trendelenburg positioning can
increase ICP. Elevation beyond 30° may compromise CPP in hypotensive
patients.
, 6. The nurse is caring for a client with a TBI and a subdural hematoma.
Which intervention should the nurse question in the treatment plan to
avoid increasing ICP?
• A) Administering mannitol as prescribed
• B) Positioning with the head of the bed elevated 30 degrees
• C) Clustering all nursing care activities to minimize interruptions
• D) Administering hypertonic saline as prescribed
Correct ,,,,answer,,,: C
Rationale: While minimal stimulation is needed, clustering too many
activities (e.g., turning, suctioning, vital signs) without allowing recovery
time can cause ICP spikes. Care should be spaced out, not clustered.
Mannitol and hypertonic saline are standard osmotic therapies to reduce
cerebral edema.
7. A client with a Glasgow Coma Scale (GCS) score of 6 is receiving
mechanical ventilation. The nurse should be most concerned with which
finding?
• A) ICP 15 mmHg
• B) CPP 68 mmHg
• C) Unequal pupil size with sluggish reaction
• D) Temperature 98.6°F (37°C)
Correct ,,,,answer,,,: C
Rationale: A GCS ≤ 8 indicates severe TBI. New or worsening pupillary
asymmetry and sluggish reaction is a sign of uncal herniation and requires
immediate intervention (e.g., mannitol, hyperventilation, neurosurgical
consult). The other findings are within acceptable ranges.
Answers | 2026 Update | 100% Correct –
Galen College.
1. A client is admitted to the emergency department (ED) following a
motor vehicle crash and has sustained a traumatic brain injury (TBI). The
nurse assesses the client and notes posturing characterized by rigid
extension of all four extremities, plantar flexion, and internal rotation of
the arms. The nurse correctly documents this as:
• A) Decerebrate posturing
• B) Decorticate posturing
• C) Flaccid posturing
• D) Opisthotonos
Correct ,,,,answer,,,: A
Rationale: Decerebrate posturing (extension of all extremities) indicates
severe damage at the level of the brainstem, below the red nucleus
(midbrain). It has a worse prognosis than decorticate posturing, which is
flexion of the upper extremities. This distinction is crucial in a TBI
assessment.
2. The nurse is caring for a client with severe traumatic brain injury.
Increased intracranial pressure (ICP) is suspected. Which cerebral
perfusion pressure (CPP) range would the nurse recognize as appropriate
for maintaining adequate brain perfusion?
, • A) 20 to 40 mmHg
• B) 30 to 50 mmHg
• C) 40 to 60 mmHg
• D) 60 to 100 mmHg
Correct ,,,,answer,,,: D
Rationale: CPP is calculated as MAP – ICP, with a normal range of 70–100
mmHg. A CPP below 50–60 mmHg is associated with cerebral ischemia
and poor neurological outcomes. Maintaining CPP above 60 mmHg is a
therapeutic goal in severe TBI.
3. A client with a TBI is being monitored for ICP. The ICP reading has been
22 mmHg for the last hour. Which finding would the nurse anticipate as an
early sign of deterioration?
• A) Widening pulse pressure
• B) Bradycardia and irregular respirations
• C) Ipsilateral pupil dilation (blown pupil)
• D) Decreasing level of consciousness
Correct ,,,,answer,,,: D
Rationale: A decreased level of consciousness (lethargy, confusion) is
often the earliest sign of rising ICP. Cushing's triad (hypertension,
bradycardia, irregular respirations) and pupillary changes occur later and
herald impending herniation. Early recognition is key.
,4. A client with a TBI is intubated and mechanically ventilated. The nurse
would anticipate which PaCO₂ range to help manage ICP?
• A) 20 to 25 mmHg (mild hyperventilation)
• B) 25 to 30 mmHg (mild hyperventilation)
• C) 35 to 45 mmHg (normocapnia)
• D) 45 to 50 mmHg (permissive hypercapnia)
Correct ,,,,answer,,,: C
Rationale: Maintaining PaCO₂ in the normal range (35–45 mmHg) is
recommended in TBI. Hyperventilation (PaCO₂ < 35 mmHg)
vasoconstricts cerebral vessels and lowers ICP but can cause cerebral
ischemia and is reserved for acute herniation crises.
5. A client has a sustained ICP of 28 mmHg. The nurse should position the
client with the head of the bed:
• A) Flat
• B) Elevated 15 to 30 degrees
• C) Elevated 45 to 60 degrees
• D) In a Trendelenburg position
Correct ,,,,answer,,,: B
Rationale: For ICP management, the head of the bed is
generally elevated to 30° (or 15–30°). This promotes venous drainage
from the head, reducing ICP. Flat or Trendelenburg positioning can
increase ICP. Elevation beyond 30° may compromise CPP in hypotensive
patients.
, 6. The nurse is caring for a client with a TBI and a subdural hematoma.
Which intervention should the nurse question in the treatment plan to
avoid increasing ICP?
• A) Administering mannitol as prescribed
• B) Positioning with the head of the bed elevated 30 degrees
• C) Clustering all nursing care activities to minimize interruptions
• D) Administering hypertonic saline as prescribed
Correct ,,,,answer,,,: C
Rationale: While minimal stimulation is needed, clustering too many
activities (e.g., turning, suctioning, vital signs) without allowing recovery
time can cause ICP spikes. Care should be spaced out, not clustered.
Mannitol and hypertonic saline are standard osmotic therapies to reduce
cerebral edema.
7. A client with a Glasgow Coma Scale (GCS) score of 6 is receiving
mechanical ventilation. The nurse should be most concerned with which
finding?
• A) ICP 15 mmHg
• B) CPP 68 mmHg
• C) Unequal pupil size with sluggish reaction
• D) Temperature 98.6°F (37°C)
Correct ,,,,answer,,,: C
Rationale: A GCS ≤ 8 indicates severe TBI. New or worsening pupillary
asymmetry and sluggish reaction is a sign of uncal herniation and requires
immediate intervention (e.g., mannitol, hyperventilation, neurosurgical
consult). The other findings are within acceptable ranges.
