NUR 265 EXAM 3 REVIEW 2026 –
QUESTIONS AND ANSWERS | LATEST
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Question: What are the major physiological complications that can develop
following a Traumatic Brain Injury (TBI)?
Answer: ✔✔ The development of a secondary brain injury (cellular damage
triggered by subsequent ischemia, inflammation, or swelling), severe systemic
hypotension, and decreased cerebral perfusion pressure (CPP), which deprives
neural tissues of essential oxygen.
Question: What are the critical nursing interventions and management protocols
for a patient with an acute TBI?
Answer: ✔✔
Prioritize the ABCs: Secure and maintain optimal oxygenation and
ventilation above all else.
Cervical Spine Protection: Ensure the patient remains flat on the
backboard with the cervical collar secured; do not remove the stabilizer until
the spine is cleared radiologically.
Body Positioning: Elevate the head of the bed (typically 30–45 degrees)
while keeping the neck in a strict midline alignment to facilitate venous
drainage. Avoid excessive hip flexion, which elevates intra-abdominal and
intracranial pressures. Use the log-roll technique for all repositioning.
Fluid & Swelling Assessment: Meticulously monitor for rising intracranial
pressure. Inspect any clear fluid draining from the nose or ears for a positive
glucose strip or a halo sign (blood pooling in the center with a clear ring
around it), indicating a cerebrospinal fluid (CSF) leak.
Ventilatory Strategy: If ordered during an acute spike in pressure,
temporarily hyperventilate the patient to drop carbon dioxide ($CO_2$)
levels, inducing cerebral vasoconstriction to briefly reduce intracranial
volume.
Question: What are the clinical signs and symptoms of worsening or increased
Intracranial Pressure (ICP)?
, Answer: ✔✔
Early Signs: An altered level of consciousness (LOC)—such as
restlessness, confusion, or agitation—along with a progressive headache and
vomiting (often projectile) that is unassociated with nausea.
Late Signs: Unilateral or bilateral pupillary dilation, sluggish or non-
reactive responses to light, brainstem compression, and a progressive loss of
protective reflexes (corneal, gag, and swallow).
Question: Which osmotic diuretic is classically administered to rapidly reduce
elevated intracranial pressure?
Answer: ✔✔ Mannitol. It works by pulling water out of edematous brain tissue
and drawing it into the vascular space to be excreted by the kidneys.
Question: What life-threatening complication is associated with high cervical
spinal cord injuries (typically at or above the C4 level)?
Answer: ✔✔ Respiratory compromise. Injuries in this region disrupt the phrenic
nerve, paralyzing the diaphragm and leading to immediate respiratory arrest or
insufficiency.
Question: What are the three classic components of Cushing's Triad, and what
does its presence signify?
Answer: ✔✔ A widened pulse pressure (rising systolic blood pressure alongside
a stable or dropping diastolic pressure), bradycardia (a dangerously slow heart
rate), and irregular, altered respirations (such as Cheyne-Stokes breathing).
Critical Clinical Alert: The appearance of Cushing's Triad is a late, ominous sign
indicating imminent brainstem herniation due to severely elevated intracranial
pressure. This is a medical emergency requiring immediate decompression or
hyperosmolar therapy.
What is decorticate posturing? -ANSWER ✔✔Extremities are pointing towards the
"core" meaning severe brain damage
QUESTIONS AND ANSWERS | LATEST
UPDATE GUARANTEED SUCCESS!!!
Question: What are the major physiological complications that can develop
following a Traumatic Brain Injury (TBI)?
Answer: ✔✔ The development of a secondary brain injury (cellular damage
triggered by subsequent ischemia, inflammation, or swelling), severe systemic
hypotension, and decreased cerebral perfusion pressure (CPP), which deprives
neural tissues of essential oxygen.
Question: What are the critical nursing interventions and management protocols
for a patient with an acute TBI?
Answer: ✔✔
Prioritize the ABCs: Secure and maintain optimal oxygenation and
ventilation above all else.
Cervical Spine Protection: Ensure the patient remains flat on the
backboard with the cervical collar secured; do not remove the stabilizer until
the spine is cleared radiologically.
Body Positioning: Elevate the head of the bed (typically 30–45 degrees)
while keeping the neck in a strict midline alignment to facilitate venous
drainage. Avoid excessive hip flexion, which elevates intra-abdominal and
intracranial pressures. Use the log-roll technique for all repositioning.
Fluid & Swelling Assessment: Meticulously monitor for rising intracranial
pressure. Inspect any clear fluid draining from the nose or ears for a positive
glucose strip or a halo sign (blood pooling in the center with a clear ring
around it), indicating a cerebrospinal fluid (CSF) leak.
Ventilatory Strategy: If ordered during an acute spike in pressure,
temporarily hyperventilate the patient to drop carbon dioxide ($CO_2$)
levels, inducing cerebral vasoconstriction to briefly reduce intracranial
volume.
Question: What are the clinical signs and symptoms of worsening or increased
Intracranial Pressure (ICP)?
, Answer: ✔✔
Early Signs: An altered level of consciousness (LOC)—such as
restlessness, confusion, or agitation—along with a progressive headache and
vomiting (often projectile) that is unassociated with nausea.
Late Signs: Unilateral or bilateral pupillary dilation, sluggish or non-
reactive responses to light, brainstem compression, and a progressive loss of
protective reflexes (corneal, gag, and swallow).
Question: Which osmotic diuretic is classically administered to rapidly reduce
elevated intracranial pressure?
Answer: ✔✔ Mannitol. It works by pulling water out of edematous brain tissue
and drawing it into the vascular space to be excreted by the kidneys.
Question: What life-threatening complication is associated with high cervical
spinal cord injuries (typically at or above the C4 level)?
Answer: ✔✔ Respiratory compromise. Injuries in this region disrupt the phrenic
nerve, paralyzing the diaphragm and leading to immediate respiratory arrest or
insufficiency.
Question: What are the three classic components of Cushing's Triad, and what
does its presence signify?
Answer: ✔✔ A widened pulse pressure (rising systolic blood pressure alongside
a stable or dropping diastolic pressure), bradycardia (a dangerously slow heart
rate), and irregular, altered respirations (such as Cheyne-Stokes breathing).
Critical Clinical Alert: The appearance of Cushing's Triad is a late, ominous sign
indicating imminent brainstem herniation due to severely elevated intracranial
pressure. This is a medical emergency requiring immediate decompression or
hyperosmolar therapy.
What is decorticate posturing? -ANSWER ✔✔Extremities are pointing towards the
"core" meaning severe brain damage
