NR 325 Adult Health III Exam 8 Study Guide 2026 |Chamberlain
College
1. A patient with a T4 spinal cord injury reports a sudden, severe pounding
headache and nasal congestion. Their blood pressure is 190/100 mmHg. What is
the nurse’s priority action?
A. Elevate the head of the bed to 45 degrees or higher
B. Check the patient’s bladder for distention
C. Administer an ordered antihypertensive medication
D. Assess the patient’s skin for pressure ulcers
Answer: A
Rationale: The patient is experiencing autonomic dysreflexia. The first priority is to sit the
patient up to lower blood pressure via orthostatic effect, followed by identifying and
removing the noxious stimulus.
2. Which Glasgow Coma Scale (GCS) score would require immediate nursing
intervention and possible intubation?
A. GCS of 7
B. GCS of 13
C. GCS of 10
D. GCS of 15
Answer: A
Rationale: A GCS score of 8 or less indicates severe brain injury and the patient typically
cannot maintain their airway, requiring intubation.
,3. A nurse is monitoring a patient for signs of increased intracranial pressure
(ICP). Which of the following is the earliest indicator of neurological
deterioration?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Change in level of consciousness
D. Decerebrate posturing
Answer: C
Rationale: A change in level of consciousness (LOC) is the most sensitive and earliest
indicator of increased ICP and neurological changes.
4. Cushing’s triad is a late sign of increased ICP. Which clinical manifestations
comprise this triad?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, widened pulse pressure, and irregular respirations
C. Hypotension, bradycardia, and Cheyne-Stokes respirations
D. Hypertension, tachycardia, and narrowed pulse pressure
Answer: B
Rationale: Cushing’s triad consists of systolic hypertension with a widened pulse pressure,
bradycardia, and irregular or slowed respirations.
5. A nurse is administering IV Mannitol to a patient with a traumatic brain
injury. What is the primary purpose of this medication?
A. To prevent seizure activity
B. To sedate the patient for mechanical ventilation
C. To maintain a high blood pressure for cerebral perfusion
D. To reduce cerebral edema by osmotic diuresis
Answer: D
, Rationale: Mannitol is an osmotic diuretic that draws water out of the brain tissue into the
vascular space to reduce cerebral edema and ICP.
6. Which type of posturing is characterized by the patient extending their arms
and legs, with toes pointed downward and head arched back?
A. Decorticate posturing
B. Flaccid paralysis
C. Decerebrate posturing
D. Opisthotonos
Answer: C
Rationale: Decerebrate posturing (extensor) involves the stiff extension of arms and legs
and indicates more severe damage to the brainstem compared to decorticate posturing.
7. A patient is admitted with spinal shock following a spinal cord injury. Which
finding is characteristic of this condition?
A. Loss of all reflexes and flaccid paralysis below the level of injury
B. Spastic paralysis below the level of injury
C. Severe hypertension and bradycardia
D. Hyperreflexia and bladder spasms
Answer: A
Rationale: Spinal shock is a temporary phase characterized by the loss of all reflex activity
and flaccid paralysis below the level of the spinal cord injury.
8. How does neurogenic shock differ from hypovolemic shock in terms of heart
rate?
A. In neurogenic shock, the patient is tachycardic; in hypovolemic, they are bradycardic
B. In neurogenic shock, the patient is bradycardic; in hypovolemic, they are tachycardic
C. Both types of shock cause severe tachycardia
D. Heart rate is not affected in either type of shock
Answer: B
College
1. A patient with a T4 spinal cord injury reports a sudden, severe pounding
headache and nasal congestion. Their blood pressure is 190/100 mmHg. What is
the nurse’s priority action?
A. Elevate the head of the bed to 45 degrees or higher
B. Check the patient’s bladder for distention
C. Administer an ordered antihypertensive medication
D. Assess the patient’s skin for pressure ulcers
Answer: A
Rationale: The patient is experiencing autonomic dysreflexia. The first priority is to sit the
patient up to lower blood pressure via orthostatic effect, followed by identifying and
removing the noxious stimulus.
2. Which Glasgow Coma Scale (GCS) score would require immediate nursing
intervention and possible intubation?
A. GCS of 7
B. GCS of 13
C. GCS of 10
D. GCS of 15
Answer: A
Rationale: A GCS score of 8 or less indicates severe brain injury and the patient typically
cannot maintain their airway, requiring intubation.
,3. A nurse is monitoring a patient for signs of increased intracranial pressure
(ICP). Which of the following is the earliest indicator of neurological
deterioration?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Change in level of consciousness
D. Decerebrate posturing
Answer: C
Rationale: A change in level of consciousness (LOC) is the most sensitive and earliest
indicator of increased ICP and neurological changes.
4. Cushing’s triad is a late sign of increased ICP. Which clinical manifestations
comprise this triad?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, widened pulse pressure, and irregular respirations
C. Hypotension, bradycardia, and Cheyne-Stokes respirations
D. Hypertension, tachycardia, and narrowed pulse pressure
Answer: B
Rationale: Cushing’s triad consists of systolic hypertension with a widened pulse pressure,
bradycardia, and irregular or slowed respirations.
5. A nurse is administering IV Mannitol to a patient with a traumatic brain
injury. What is the primary purpose of this medication?
A. To prevent seizure activity
B. To sedate the patient for mechanical ventilation
C. To maintain a high blood pressure for cerebral perfusion
D. To reduce cerebral edema by osmotic diuresis
Answer: D
, Rationale: Mannitol is an osmotic diuretic that draws water out of the brain tissue into the
vascular space to reduce cerebral edema and ICP.
6. Which type of posturing is characterized by the patient extending their arms
and legs, with toes pointed downward and head arched back?
A. Decorticate posturing
B. Flaccid paralysis
C. Decerebrate posturing
D. Opisthotonos
Answer: C
Rationale: Decerebrate posturing (extensor) involves the stiff extension of arms and legs
and indicates more severe damage to the brainstem compared to decorticate posturing.
7. A patient is admitted with spinal shock following a spinal cord injury. Which
finding is characteristic of this condition?
A. Loss of all reflexes and flaccid paralysis below the level of injury
B. Spastic paralysis below the level of injury
C. Severe hypertension and bradycardia
D. Hyperreflexia and bladder spasms
Answer: A
Rationale: Spinal shock is a temporary phase characterized by the loss of all reflex activity
and flaccid paralysis below the level of the spinal cord injury.
8. How does neurogenic shock differ from hypovolemic shock in terms of heart
rate?
A. In neurogenic shock, the patient is tachycardic; in hypovolemic, they are bradycardic
B. In neurogenic shock, the patient is bradycardic; in hypovolemic, they are tachycardic
C. Both types of shock cause severe tachycardia
D. Heart rate is not affected in either type of shock
Answer: B
