NUR 417 FINAL EXAM
NUR 417 FINAL EXAM NEWEST 2026/2027 ACTUAL EXAM
COMPLETE 130 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) WITH DETAILED RATIONALES |ALREADY
GRADED A+||BRAND NEW VERSION!!
The nurse is caring for a patient who is disoriented and anxious as result of
increased
intracranial pressure. Which of the following nursing actions should be included in
the plan of
care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input - Correct Answer-
ANS: A
Patients with disorientation as result of increased ICP will be calmed by the
presence of
someone familiar at the bedside. Restraints should be avoided because they
increase agitation
and anxiety. The patient requires frequent assessment for complications; the use
of touch and a
soothing voice will decrease anxiety for most patients. The patient will have
photophobia, so
the light should be dim.
1|Page
, NUR 417 FINAL EXAM
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an
intracranial pressure
(ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP. - Correct Answer-ANS: C
The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP=
MAPICP), below the normal of 70-100 mm Hg and approaching the level of
ischemia and
neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral
perfusion.
Immediate changes in the patient's therapy such as fluid infusion or vasopressor
administration are needed to improve the cerebral perfusion pressure.
Adjustments in the head
elevation should only be done after consulting with the health care provider.
Continued
monitoring and documentation also will be done, but they are not the first actions
that the
nurse should take.
The nurse is suctioning a patient with a traumatic head injury and notes that the
intracranial
pressure has increased from 14 to 16 mm Hg. Which of the following actions
should the nurse
2|Page
, NUR 417 FINAL EXAM
take first?
a. Document the increase in intracranial pressure.
b. Assure that the patient's neck is not in a flexed position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol infusion. - Correct Answer-ANS: B
Since suctioning will cause a transient increase in intracranial pressure, the nurse
should
initially check for other factors that might be contributing to the increase and
observe the
patient for a few minutes. Documentation is needed, but this is not the first action.
There is no
need to notify the health care provider about this expected reaction to suctioning.
Propofol is
used to control patient anxiety or agitation; there is no indication that anxiety has
contributed
to the increase in intracranial pressure.
After receiving change of shift report, which of the following patients should the
nurse assess first?
a. A 44-year-old receiving IV antibiotics for meningococcal meningitis
b. A 23-year-old who had a skull fracture and craniotomy the previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a
head injury a week ago
d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy -
Correct Answer-ANS: D
3|Page
, NUR 417 FINAL EXAM
The patient that should be seen first is the one that requires the closest
monitoring—the
patient with ICP and receiving hyperventilation therapy. The postcraniotomy
patient, patient
with an ICP monitor, and the patient on IV antibiotics should be assessed as well
but the
priority would be the most critically ill patients.
The nurse is caring for a patient with possible cerebral edema who has a serum
sodium level
of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache.
Which of the
following prescribed interventions should the nurse implement first?
a. Draw blood for arterial blood gases (ABGs).
b. Administer 5% hypertonic saline intravenously.
c. Administer acetaminophen 650 mg orally.
d. Send patient for computed tomography (CT) of the head. - Correct Answer-ANS:
B The patient's low sodium indicates that hyponatremia may be causing the
cerebral edema, and the nurse's first action should be to correct the low sodium
level. Acetaminophen will have minimal effect on the headache because it is
caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs
and obtaining a CT scan may add some useful information, but the low sodium
level may lead to seizures unless it is addressed quickly.
Family members ask the nurse about the purpose of the ventriculostomy system
being used
4|Page
NUR 417 FINAL EXAM NEWEST 2026/2027 ACTUAL EXAM
COMPLETE 130 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) WITH DETAILED RATIONALES |ALREADY
GRADED A+||BRAND NEW VERSION!!
The nurse is caring for a patient who is disoriented and anxious as result of
increased
intracranial pressure. Which of the following nursing actions should be included in
the plan of
care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input - Correct Answer-
ANS: A
Patients with disorientation as result of increased ICP will be calmed by the
presence of
someone familiar at the bedside. Restraints should be avoided because they
increase agitation
and anxiety. The patient requires frequent assessment for complications; the use
of touch and a
soothing voice will decrease anxiety for most patients. The patient will have
photophobia, so
the light should be dim.
1|Page
, NUR 417 FINAL EXAM
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an
intracranial pressure
(ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP. - Correct Answer-ANS: C
The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP=
MAPICP), below the normal of 70-100 mm Hg and approaching the level of
ischemia and
neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral
perfusion.
Immediate changes in the patient's therapy such as fluid infusion or vasopressor
administration are needed to improve the cerebral perfusion pressure.
Adjustments in the head
elevation should only be done after consulting with the health care provider.
Continued
monitoring and documentation also will be done, but they are not the first actions
that the
nurse should take.
The nurse is suctioning a patient with a traumatic head injury and notes that the
intracranial
pressure has increased from 14 to 16 mm Hg. Which of the following actions
should the nurse
2|Page
, NUR 417 FINAL EXAM
take first?
a. Document the increase in intracranial pressure.
b. Assure that the patient's neck is not in a flexed position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol infusion. - Correct Answer-ANS: B
Since suctioning will cause a transient increase in intracranial pressure, the nurse
should
initially check for other factors that might be contributing to the increase and
observe the
patient for a few minutes. Documentation is needed, but this is not the first action.
There is no
need to notify the health care provider about this expected reaction to suctioning.
Propofol is
used to control patient anxiety or agitation; there is no indication that anxiety has
contributed
to the increase in intracranial pressure.
After receiving change of shift report, which of the following patients should the
nurse assess first?
a. A 44-year-old receiving IV antibiotics for meningococcal meningitis
b. A 23-year-old who had a skull fracture and craniotomy the previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a
head injury a week ago
d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy -
Correct Answer-ANS: D
3|Page
, NUR 417 FINAL EXAM
The patient that should be seen first is the one that requires the closest
monitoring—the
patient with ICP and receiving hyperventilation therapy. The postcraniotomy
patient, patient
with an ICP monitor, and the patient on IV antibiotics should be assessed as well
but the
priority would be the most critically ill patients.
The nurse is caring for a patient with possible cerebral edema who has a serum
sodium level
of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache.
Which of the
following prescribed interventions should the nurse implement first?
a. Draw blood for arterial blood gases (ABGs).
b. Administer 5% hypertonic saline intravenously.
c. Administer acetaminophen 650 mg orally.
d. Send patient for computed tomography (CT) of the head. - Correct Answer-ANS:
B The patient's low sodium indicates that hyponatremia may be causing the
cerebral edema, and the nurse's first action should be to correct the low sodium
level. Acetaminophen will have minimal effect on the headache because it is
caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs
and obtaining a CT scan may add some useful information, but the low sodium
level may lead to seizures unless it is addressed quickly.
Family members ask the nurse about the purpose of the ventriculostomy system
being used
4|Page
