NUR 265/ NUR265 Exam 3 – (New 2026/ 2027
Update) Advanced Concepts of Medical-
Surgical Nursing Guide| Questions & Answers |
Grade A| 100% Correct (Verified Solutions)-
Galen
Section 1: Increased Intracranial Pressure (ICP) & Traumatic Brain
Injury (TBI) (Q1-Q20)
Q1. The nurse is caring for an adult client admitted with a head injury
following a motor vehicle crash. One hour ago, vital signs were: T
98.6°F, P 110, R 26, BP 128/68 mm Hg. Current VS: P 56, R 14, BP 166/52
mm Hg. Which finding is the priority for the nurse to follow up?
A) Pulse 56 bpm
B) Respirations 14 per minute
C) Blood pressure 166/52 mm Hg
D) Temperature 98.6°F
Correct ,,,,,,answer,,,,,,,,: A
Rationale: Bradycardia (56 bpm) combined with hypertension and
irregular respirations indicates Cushing's triad, a classic sign of increased
intracranial pressure (ICP) and impending brain herniation. The decrease
in pulse rate from 110 to 56 with a rising BP is an ominous neurological
sign requiring immediate intervention .
Q2. The nurse is caring for a client with a closed head injury receiving
mechanical ventilation who is at risk for increased ICP. Which action
,should the nurse take?
A) Log roll the client during turning and repositioning
B) Perform frequent head and neck flexion exercises
C) Cluster care activities to minimize disturbance
D) Keep the client flat in bed to improve cerebral perfusion
Correct ,,,,,,answer,,,,,,,,: A
Rationale: Log rolling maintains spinal alignment and prevents neck
flexion or rotation, which can impede venous drainage from the brain and
increase ICP. Clustering care activities is discouraged as it can cause ICP
spikes .
Q3. The newly hired nurse is caring for a client admitted 12 hours ago
with a TBI who is intubated and at risk for increased ICP. Which
interventions should be included in the plan of care? (Select all that
apply)
1. Avoid clustering client care activities
2. Maintain the head in a flexed position
3. Provide a quiet environment by limiting visitors
4. Have the client cough and deep breathe every hour
5. Hyperoxygenate the client before and after suctioning
6. Avoid maintaining hips in a flexed position
A) 1, 3, 4, 5
B) 1, 3, 5, 6
C) 1, 2, 4, 6
D) 2, 4, 6
,Correct ,,,,,,answer,,,,,,,,: B
Rationale: Key ICP-reducing interventions include: avoiding clustering
care, quiet environment, hyperoxygenation before suctioning, and
avoiding hip flexion. Head flexion should be avoided (impedes venous
drainage), and coughing increases ICP .
Q4. The nurse is assessing a client who has experienced a mild TBI.
Which findings are consistent with this diagnosis? (Select all that
apply)
A) Dizziness and gait problems
B) Increased sensitivity to light or noise
C) Amnesia about events around time of injury
D) Seizures
E) Hemiplegia
Correct ,,,,,,answer,,,,,,,,s: A, B, C
Rationale: Mild TBI (concussion) commonly presents with dizziness, gait
imbalance, light/noise sensitivity, and transient amnesia. Loss of
consciousness may or may not occur. Seizures and hemiplegia are
consistent with moderate to severe brain injury .
Q5. The nurse is providing discharge instructions to the parents of a 15-
year-old female who sustained a concussion while playing field hockey.
Which statement indicates a need for further teaching?
A) "We should avoid giving any acetaminophen to treat headaches."
B) "She should avoid strenuous activities until cleared by provider."
C) "Watch for increased drowsiness or confusion."
D) "Limit her exposure to screens to reduce symptoms."
, Correct ,,,,,,answer,,,,,,,,: A
Rationale: Acetaminophen is recommended for post-concussion
headaches because it does not interfere with platelet function (unlike
NSAIDs, which increase bleeding risk). Complete avoidance is incorrect .
Q6. The nurse is assessing clients for the risk of sustaining a TBI. Which
client is at greatest risk?
A) 28-year-old professional athlete
B) 45-year-old construction worker
C) 75-year-old who lives alone and has macular degeneration
D) 19-year-old college student who rides a motorcycle
Correct ,,,,,,answer,,,,,,,,: C
Rationale: Older adults, especially those living alone with sensory deficits
like macular degeneration, have a high risk for falls resulting in TBIs. While
young adults may engage in risk-taking behaviors, older adults have the
highest incidence of TBI related to falls .
Q7. The nurse is caring for a client with a TBI who has a Glasgow Coma
Scale (GCS) score of 6. What is the priority nursing intervention?
A) Maintain the head of the bed flat
B) Provide range of motion exercises every 4 hours
C) Maintain a patent airway
D) Provide stimulation to increase responsiveness
Correct ,,,,,,answer,,,,,,,,: C
Rationale: A GCS of 6 indicates severe brain injury with impaired airway
Update) Advanced Concepts of Medical-
Surgical Nursing Guide| Questions & Answers |
Grade A| 100% Correct (Verified Solutions)-
Galen
Section 1: Increased Intracranial Pressure (ICP) & Traumatic Brain
Injury (TBI) (Q1-Q20)
Q1. The nurse is caring for an adult client admitted with a head injury
following a motor vehicle crash. One hour ago, vital signs were: T
98.6°F, P 110, R 26, BP 128/68 mm Hg. Current VS: P 56, R 14, BP 166/52
mm Hg. Which finding is the priority for the nurse to follow up?
A) Pulse 56 bpm
B) Respirations 14 per minute
C) Blood pressure 166/52 mm Hg
D) Temperature 98.6°F
Correct ,,,,,,answer,,,,,,,,: A
Rationale: Bradycardia (56 bpm) combined with hypertension and
irregular respirations indicates Cushing's triad, a classic sign of increased
intracranial pressure (ICP) and impending brain herniation. The decrease
in pulse rate from 110 to 56 with a rising BP is an ominous neurological
sign requiring immediate intervention .
Q2. The nurse is caring for a client with a closed head injury receiving
mechanical ventilation who is at risk for increased ICP. Which action
,should the nurse take?
A) Log roll the client during turning and repositioning
B) Perform frequent head and neck flexion exercises
C) Cluster care activities to minimize disturbance
D) Keep the client flat in bed to improve cerebral perfusion
Correct ,,,,,,answer,,,,,,,,: A
Rationale: Log rolling maintains spinal alignment and prevents neck
flexion or rotation, which can impede venous drainage from the brain and
increase ICP. Clustering care activities is discouraged as it can cause ICP
spikes .
Q3. The newly hired nurse is caring for a client admitted 12 hours ago
with a TBI who is intubated and at risk for increased ICP. Which
interventions should be included in the plan of care? (Select all that
apply)
1. Avoid clustering client care activities
2. Maintain the head in a flexed position
3. Provide a quiet environment by limiting visitors
4. Have the client cough and deep breathe every hour
5. Hyperoxygenate the client before and after suctioning
6. Avoid maintaining hips in a flexed position
A) 1, 3, 4, 5
B) 1, 3, 5, 6
C) 1, 2, 4, 6
D) 2, 4, 6
,Correct ,,,,,,answer,,,,,,,,: B
Rationale: Key ICP-reducing interventions include: avoiding clustering
care, quiet environment, hyperoxygenation before suctioning, and
avoiding hip flexion. Head flexion should be avoided (impedes venous
drainage), and coughing increases ICP .
Q4. The nurse is assessing a client who has experienced a mild TBI.
Which findings are consistent with this diagnosis? (Select all that
apply)
A) Dizziness and gait problems
B) Increased sensitivity to light or noise
C) Amnesia about events around time of injury
D) Seizures
E) Hemiplegia
Correct ,,,,,,answer,,,,,,,,s: A, B, C
Rationale: Mild TBI (concussion) commonly presents with dizziness, gait
imbalance, light/noise sensitivity, and transient amnesia. Loss of
consciousness may or may not occur. Seizures and hemiplegia are
consistent with moderate to severe brain injury .
Q5. The nurse is providing discharge instructions to the parents of a 15-
year-old female who sustained a concussion while playing field hockey.
Which statement indicates a need for further teaching?
A) "We should avoid giving any acetaminophen to treat headaches."
B) "She should avoid strenuous activities until cleared by provider."
C) "Watch for increased drowsiness or confusion."
D) "Limit her exposure to screens to reduce symptoms."
, Correct ,,,,,,answer,,,,,,,,: A
Rationale: Acetaminophen is recommended for post-concussion
headaches because it does not interfere with platelet function (unlike
NSAIDs, which increase bleeding risk). Complete avoidance is incorrect .
Q6. The nurse is assessing clients for the risk of sustaining a TBI. Which
client is at greatest risk?
A) 28-year-old professional athlete
B) 45-year-old construction worker
C) 75-year-old who lives alone and has macular degeneration
D) 19-year-old college student who rides a motorcycle
Correct ,,,,,,answer,,,,,,,,: C
Rationale: Older adults, especially those living alone with sensory deficits
like macular degeneration, have a high risk for falls resulting in TBIs. While
young adults may engage in risk-taking behaviors, older adults have the
highest incidence of TBI related to falls .
Q7. The nurse is caring for a client with a TBI who has a Glasgow Coma
Scale (GCS) score of 6. What is the priority nursing intervention?
A) Maintain the head of the bed flat
B) Provide range of motion exercises every 4 hours
C) Maintain a patent airway
D) Provide stimulation to increase responsiveness
Correct ,,,,,,answer,,,,,,,,: C
Rationale: A GCS of 6 indicates severe brain injury with impaired airway
