NUR 265 Exam 3 | Questions and
Answers | 2026 Update | 100% Correct –
Galen College.
Section 1: Traumatic Brain Injury & Increased ICP (Questions 1-20)
1. The nurse is caring for a client with a traumatic brain injury (TBI). Which
assessment finding is most indicative of increased intracranial pressure (ICP)?
• A. Hypotension and tachycardia
• B. Hypertension and bradycardia
• C. Hypertension and tachycardia
• D. Hypotension and bradycardia
Correct ,,,,answer,,,,: B
Rationale: Cushing's triad (hypertension, bradycardia, and irregular respirations)
is a late sign of increased ICP and indicates impending herniation. This is a
medical emergency requiring immediate intervention.
2. A client with a TBI has an ICP of 28 mmHg and a CPP of 52 mmHg. Which
intervention should the nurse implement first?
• A. Administer mannitol 0.5–1 g/kg IV
• B. Elevate the head of the bed (HOB) to 30–45 degrees and maintain neutral
head alignment
• C. Hyperventilate the patient to a PaCO₂ of 25 mmHg
, • D. Initiate a propofol infusion for sedation
Correct ,,,,answer,,,,: B
Rationale: First-line, non-pharmacologic measures to reduce ICP include
elevating the HOB to 30–45 degrees and maintaining the head in a neutral, midline
position to promote venous drainage. Osmotic diuretics and brief hyperventilation
are used for acute herniation emergencies.
3. The nurse is assessing a client with a TBI. Which Glasgow Coma Scale
(GCS) score indicates the most severe impairment?
• A. 15
• B. 12
• C. 8
• D. 3
Correct ,,,,answer,,,,: D
Rationale: The GCS ranges from 3 (most severe impairment) to 15 (normal). A
score of 8 or less indicates severe brain injury and coma. A score of 3 indicates no
eye opening, no verbal response, and no motor response.
4. A client with a TBI has a PaCO₂ of 55 mmHg. The nurse should anticipate
which intervention?
• A. Increasing the respiratory rate on the ventilator
• B. Decreasing the respiratory rate on the ventilator
• C. Administering sodium bicarbonate
• D. No change in ventilator settings
,Correct ,,,,answer,,,,: A
Rationale: Hypercapnia (PaCO₂ > 45 mmHg) causes cerebral vasodilation, which
increases ICP. The ventilator rate should be increased to lower PaCO₂ to 35–40
mmHg. Overly aggressive hyperventilation (PaCO₂ < 30 mmHg) should be
avoided as it can cause cerebral ischemia.
5. Which medication is used to reduce ICP in a client with a TBI?
• A. Mannitol
• B. Furosemide
• C. Spironolactone
• D. Hydrochlorothiazide
Correct ,,,,answer,,,,: A
Rationale: Mannitol is an osmotic diuretic that draws fluid from the brain tissue
into the vascular space, reducing cerebral edema and ICP. It is given as a rapid IV
infusion for acute ICP elevation.
6. The nurse is caring for a client with a TBI. Which finding indicates a
complication of mannitol administration?
• A. Increased urine output
• B. Decreased serum osmolality
• C. Serum sodium of 155 mEq/L
• D. Decreased ICP
Correct ,,,,answer,,,,: C
Rationale: Mannitol can cause hypernatremia and hyperosmolality due to fluid
, shifts. Serum osmolality should be monitored; mannitol is typically held if
osmolality exceeds 320 mOsm/kg to prevent renal failure. Increased urine output
and decreased ICP are desired effects.
7. A client with a TBI has an ICP of 30 mmHg. The nurse should assess for
which sign of impending herniation?
• A. Dilated, non-reactive pupil on one side
• B. Constricted, reactive pupils bilaterally
• C. Equal and reactive pupils
• D. Diplopia
Correct ,,,,answer,,,,: A
Rationale: A dilated, non-reactive pupil on one side (unilateral pupil dilation) is a
sign of uncal herniation, where the oculomotor nerve (CN III) is compressed. This
is a medical emergency requiring immediate intervention.
8. The nurse is providing discharge teaching to a client who had a mild TBI
(concussion). Which statement by the client indicates a need for further
teaching?
• A. "I should avoid activities that require concentration for the next few
days."
• B. "I need to return to the ED if I experience a severe headache or
vomiting."
• C. "I can resume all normal activities immediately."
• D. "I should avoid alcohol and sedatives."
Answers | 2026 Update | 100% Correct –
Galen College.
Section 1: Traumatic Brain Injury & Increased ICP (Questions 1-20)
1. The nurse is caring for a client with a traumatic brain injury (TBI). Which
assessment finding is most indicative of increased intracranial pressure (ICP)?
• A. Hypotension and tachycardia
• B. Hypertension and bradycardia
• C. Hypertension and tachycardia
• D. Hypotension and bradycardia
Correct ,,,,answer,,,,: B
Rationale: Cushing's triad (hypertension, bradycardia, and irregular respirations)
is a late sign of increased ICP and indicates impending herniation. This is a
medical emergency requiring immediate intervention.
2. A client with a TBI has an ICP of 28 mmHg and a CPP of 52 mmHg. Which
intervention should the nurse implement first?
• A. Administer mannitol 0.5–1 g/kg IV
• B. Elevate the head of the bed (HOB) to 30–45 degrees and maintain neutral
head alignment
• C. Hyperventilate the patient to a PaCO₂ of 25 mmHg
, • D. Initiate a propofol infusion for sedation
Correct ,,,,answer,,,,: B
Rationale: First-line, non-pharmacologic measures to reduce ICP include
elevating the HOB to 30–45 degrees and maintaining the head in a neutral, midline
position to promote venous drainage. Osmotic diuretics and brief hyperventilation
are used for acute herniation emergencies.
3. The nurse is assessing a client with a TBI. Which Glasgow Coma Scale
(GCS) score indicates the most severe impairment?
• A. 15
• B. 12
• C. 8
• D. 3
Correct ,,,,answer,,,,: D
Rationale: The GCS ranges from 3 (most severe impairment) to 15 (normal). A
score of 8 or less indicates severe brain injury and coma. A score of 3 indicates no
eye opening, no verbal response, and no motor response.
4. A client with a TBI has a PaCO₂ of 55 mmHg. The nurse should anticipate
which intervention?
• A. Increasing the respiratory rate on the ventilator
• B. Decreasing the respiratory rate on the ventilator
• C. Administering sodium bicarbonate
• D. No change in ventilator settings
,Correct ,,,,answer,,,,: A
Rationale: Hypercapnia (PaCO₂ > 45 mmHg) causes cerebral vasodilation, which
increases ICP. The ventilator rate should be increased to lower PaCO₂ to 35–40
mmHg. Overly aggressive hyperventilation (PaCO₂ < 30 mmHg) should be
avoided as it can cause cerebral ischemia.
5. Which medication is used to reduce ICP in a client with a TBI?
• A. Mannitol
• B. Furosemide
• C. Spironolactone
• D. Hydrochlorothiazide
Correct ,,,,answer,,,,: A
Rationale: Mannitol is an osmotic diuretic that draws fluid from the brain tissue
into the vascular space, reducing cerebral edema and ICP. It is given as a rapid IV
infusion for acute ICP elevation.
6. The nurse is caring for a client with a TBI. Which finding indicates a
complication of mannitol administration?
• A. Increased urine output
• B. Decreased serum osmolality
• C. Serum sodium of 155 mEq/L
• D. Decreased ICP
Correct ,,,,answer,,,,: C
Rationale: Mannitol can cause hypernatremia and hyperosmolality due to fluid
, shifts. Serum osmolality should be monitored; mannitol is typically held if
osmolality exceeds 320 mOsm/kg to prevent renal failure. Increased urine output
and decreased ICP are desired effects.
7. A client with a TBI has an ICP of 30 mmHg. The nurse should assess for
which sign of impending herniation?
• A. Dilated, non-reactive pupil on one side
• B. Constricted, reactive pupils bilaterally
• C. Equal and reactive pupils
• D. Diplopia
Correct ,,,,answer,,,,: A
Rationale: A dilated, non-reactive pupil on one side (unilateral pupil dilation) is a
sign of uncal herniation, where the oculomotor nerve (CN III) is compressed. This
is a medical emergency requiring immediate intervention.
8. The nurse is providing discharge teaching to a client who had a mild TBI
(concussion). Which statement by the client indicates a need for further
teaching?
• A. "I should avoid activities that require concentration for the next few
days."
• B. "I need to return to the ED if I experience a severe headache or
vomiting."
• C. "I can resume all normal activities immediately."
• D. "I should avoid alcohol and sedatives."
