NUR 265 Exam 3Questions and Answers | 2026Update | 100% Correct –Galen College.

NUR 265 Exam 3 Questions and Answers |
2026 Update | 100% Correct – Galen
College.

#1:Thenurseis workingintheemergencydepartment(ED)isadmittingaclient whohas sustaineda traumatic B
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braininjury(TBI)followingamotorvehiclecrash.It ispriorityforthenursetonotifytheprimary healthcare provider
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(PHCP) in the client:
Takes prescribed warfarin daily.
RATIONALE: Pg.2400.Hemorrhagemayoccuraspartoftheprimaryinjuryandbeginatthemoment of Q
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impact. Warfarin is ablood thinner and the patient maybleed out if they have ahematoma (a collectionof BQ A




blood)

#2:Thechargenurseisobservinganewlyhirednursecareforaclientwhosustainedaclosedheadinjury, is
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receivingmechanicalventilation,andisatriskfordevelopingICP.Which ofthefollowingactions,if performed
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bythenewlyhirednurse,requiresinterventionbythechargenurse?
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Raisingthefootoftheclient’sbed.
RATIONALE: Pg. 2413.Maintain the headmidline, neutral position toprevent increased ICP.




#3:Thenewlyhirednurseiscaringforaclient whowasadmitted12 hours agowitha TBIand isat riskfor Q
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developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse
is observed
Clustering client care activities
RATIONALE:pg.2387.Whenmultipleactivitiesareclusteredinarow,theeffectonICPcanbedramatic elevation. Q
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#4:ThenurseisassessingclientsfortheriskofsustainingTBI.Whichofthefollowingclientsshouldthe nurse
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identify as being at greatest risk?
20yearoldcollegestudentwhoparticipatesonthefootballteam. ,y ,




RATIONALE: Pg. 2397. A force produce by a blow direct to the head can contribute to a brain injury.


#5:Thenurseis caringforassignedclients.Whichofthefollowingassessmentfindingsrequires thenurse to
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notify the PHCP?
The development of asymmetric pupils withnoreaction to lightinthe client who hasa TBI.
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RATIONALE:Pg.2386.Pupillarychanges;dilatedandnonreactivepupils“blown”orconstrictive,non Q
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reactivepupils. Q
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#6:Thenurseiscaringforaclient whohadaTBIwithskullfracture.Thenursenotedthattheclienthas developed
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rhinorrhea(nasaldrip) that is positive f orglucose.Whichofthefollowingactionsshouldthe
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nursetakenext?
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Performahalosigntest.
RATIONALE:Pg.2410.CSFleaking,labtestwillbeanalyzedforglucoseandelectrolytecontent.Placeona white Q
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absorbent paper or linen.
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#7:Thenurseisprovidingdischargeinstructionstothepartnerofaclientwhosustainedamildhead injuryasa Q
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result ofaMVA.Which ofthefollowingstatements,ifmadebythepartnerswouldindicated the need for
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