NSG 252 / NSG252 EXAM 3 (LATEST
UPDATE 2026-2027)| COMPLETE EXAM
WITH REAL QUESTIONS AND VERIFIED
CORRECT AND DETAILED ANSWERS |
GRADED A+
QUESTION 1
The nurse notices that a client who sustained a head injury from a motor vehicle crash begins
to demonstrate an abnormal posture. (See image.) What does this posture suggest to the nurse
about the client's brain functioning?
A. Improved level of consciousness
B. Developing a seizure disorder
C. Brainstem impairment
D. Corticospinal tract impairment
Correct Answer: C
Rationale: Brain function deterioration usually follows a predictable progression in
which higher levels of function are impaired first and progress to impairment of more
primitive functions. Altered level of consciousness (LOC), not improved level of
consciousness, is an early manifestation of the deterioration of the function of the
cerebral hemispheres. Seizure disorders have various types of motor postures. Structures
in the brainstem have characteristic changes in motor function. Evidence of brainstem
involvement includes decerebrate posturing that is distinguished by rigid extension.
Corticospinal tract impairment is characterized by decorticate posturing, which is rigid
flexion.
,QUESTION 2
A newly admitted adult client with increased intracranial pressure caused from a head injury
has a Glasgow Coma Scale (GCS) score of 6. Which of the following assessment findings is
most likely in this client?
A. Extension to painful stimuli
B. Spontaneous eye opening
C. Oriented to time, place, and person
D. Withdraws to touch
Correct Answer: A
Rationale: The GCS (Glasgow Coma Scale) is a standardized system for assessment of
consciousness that analyzes three components: eye opening, verbal response, and motor
response. A score of 15 indicates full alertness, and the lowest possible score is 3, which
indicates total neurologic unresponsiveness. The client's score is low, so the finding of
extension to painful stimuli, a 2 out of a possible 6 for motor response, is most likely for
this client. Findings of spontaneous eye opening (a 4 on the scale for eye opening, the
maximum score) or orientation to time, place, and person (a 5 for verbal response and
also the maximum score for that component) are unlikely. An assessment finding of
withdraws to touch would be more typical of an infant or young child, not an adult, and
would be a 5 out of 6 for motor response.
QUESTION 3
A school-age client is experiencing photophobia, a sore neck, chills, and fever. During a
physical assessment, the nurse uses the technique in the Exhibit. Why did the nurse use this
technique when assessing the client? (See image.)
A. It is a routine part of the physical assessment.
B. Flexion of the hips or knees would be consistent with meningitis.
C. The nurse was assessing range of motion of the neck.
D. This technique assesses optic nerve functioning.
Correct Answer: B
Rationale: The client's manifestations of a sore neck, chills, fever, and photophobia are
consistent with meningitis. Assessing for the Brudzinski sign can rule in meningitis
because flexing the client's head to the chest will trigger flexion of the hips and knees in
clients with meningeal irritation. Assessing for the Brudzinski sign is not a routine part of
the physical assessment. This maneuver is not done to assess for neck range of motion or
optic nerve functioning.
QUESTION 4
The nurse is reviewing results of diagnostic testing performed on a client with increased
intracranial pressure (ICP) in preparation for an evaluation to be done by the healthcare
provider during morning rounds. Which diagnostic test results should the nurse make available
to the healthcare provider for review? (Select all that apply.)
A. Bronchoscopy results
B. MRI result
,C. Head CT scan with and without contrast
D. Electroencephalogram
E. Cerebrospinal fluid differential cell count
Correct Answer: B, C, D, E
Rationale: Diagnosis of increased ICP is made on the basis of observation and neurologic
assessment; even subtle changes can be clinically significant. Testing can include CT scan
with and without contrast, MRI, electroencephalogram, and cerebrospinal fluid
evaluation. Bronchoscopy is not performed routinely for a client with increased
intracranial pressure.
QUESTION 5
The nurse is determining ways to decrease environmental stimuli for a client with increased
intracranial pressure. Which actions should the nurse take to support this client's care need?
(Select all that apply.)
A. Limit the client's visitors.
B. Teach family to speak softly and minimize touching.
C. Elevate the head of the bed.
D. Raise pads and bedrails.
E. Keep the room dark and quiet.
Correct Answer: A, B, E
Rationale: A dark, quiet room is important to reduce stimuli. Family members should be
encouraged to talk to the client in a soft voice with minimal touching. Visitors should be
limited. Elevating the head of the bed is important to reducing intracranial pressure but
has no effect on stimulation. Raising pads and bedrails is important because of the
possibility of seizures but does not relate to stimulation.
QUESTION 6
The nurse is planning care for an older adult client with a head injury secondary to a motor
vehicle crash. Which information should the nurse keep in mind when planning this client's
care? (Select all that apply.)
A. Anxiety, illness, and pain can alter the ability to learn.
B. Baseline reflexes may be slower or diminished.
C. Impulse transmission and reactions to stimuli are slower.
D. Neurologic assessment should be completed in a single session.
E. Impairment in vision and hearing should be taken into consideration.
Correct Answer: A, B, C, E
Rationale: For an older client, full neurologic assessment can be lengthy. Conduct the
assessment in several sessions if indicated, and cease the tests if the client is noticeably
fatigued. In the older client, anxiety, illness, and pain can alter the ability to learn.
Reflexes may be slower or diminished in an older client. Responses to stimuli are slower
because of reduced impulse transmission. Many older adults have some impairment of
hearing and vision, which should be taken into consideration when planning care.
, QUESTION 7
A client with a head injury is demonstrating signs of increased intracranial pressure (IICP).
Which classifications of medications should the nurse anticipate administering to this client?
(Select all that apply.)
A. Loop diuretics
B. Antibiotics
C. Antiseizure drugs
D. Histamine H2 antagonists
E. Antipyretics
Correct Answer: A, C, D, E
Rationale: Medications play an important role in the management of IICP. Loop
diuretics are commonly used to reduce ICP. Antipyretics such as acetaminophen are used
alone or in combination with a hypothermia blanket to treat hyperthermia. Antiseizure
drugs are often required to manage seizure activity associated with brain injury and
IICP. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists is often
used because clients with IICP are at increased risk for developing stress gastritis and
ulcers. Antibiotics are not routinely prescribed as treatment for IICP.
QUESTION 8
A nurse is performing a neurologic assessment on a 9-year-old child who has displayed
unexplained changes in behavior. Which assessment finding is consistent with a neurologic
deficit?
A. Child has a negative Babinski reflex.
B. Child recalls names of well-known cartoon characters.
C. Child is able to walk backward heel to toe.
D. Child is incapable of balancing on one foot.
Correct Answer: D
Rationale: Children should be able to walk backward by 2 years of age, balance on one
foot for 5 seconds by 4 years of age, heel-toe walk by 5 years of age, and heel-toe walk
backward by 6 years of age. A positive Babinski reflex is abnormal after the child
ambulates or reaches 2 years of age. Ability to recall names of well-known cartoon
characters would show a normal level of recall.
QUESTION 9
What part of the body controls reflexes and regulates activities such as vomiting, hiccupping,
coughing, and sneezing?
A. Brainstem
B. Hypothalamus
C. Spinal cord
D. Thalamus
UPDATE 2026-2027)| COMPLETE EXAM
WITH REAL QUESTIONS AND VERIFIED
CORRECT AND DETAILED ANSWERS |
GRADED A+
QUESTION 1
The nurse notices that a client who sustained a head injury from a motor vehicle crash begins
to demonstrate an abnormal posture. (See image.) What does this posture suggest to the nurse
about the client's brain functioning?
A. Improved level of consciousness
B. Developing a seizure disorder
C. Brainstem impairment
D. Corticospinal tract impairment
Correct Answer: C
Rationale: Brain function deterioration usually follows a predictable progression in
which higher levels of function are impaired first and progress to impairment of more
primitive functions. Altered level of consciousness (LOC), not improved level of
consciousness, is an early manifestation of the deterioration of the function of the
cerebral hemispheres. Seizure disorders have various types of motor postures. Structures
in the brainstem have characteristic changes in motor function. Evidence of brainstem
involvement includes decerebrate posturing that is distinguished by rigid extension.
Corticospinal tract impairment is characterized by decorticate posturing, which is rigid
flexion.
,QUESTION 2
A newly admitted adult client with increased intracranial pressure caused from a head injury
has a Glasgow Coma Scale (GCS) score of 6. Which of the following assessment findings is
most likely in this client?
A. Extension to painful stimuli
B. Spontaneous eye opening
C. Oriented to time, place, and person
D. Withdraws to touch
Correct Answer: A
Rationale: The GCS (Glasgow Coma Scale) is a standardized system for assessment of
consciousness that analyzes three components: eye opening, verbal response, and motor
response. A score of 15 indicates full alertness, and the lowest possible score is 3, which
indicates total neurologic unresponsiveness. The client's score is low, so the finding of
extension to painful stimuli, a 2 out of a possible 6 for motor response, is most likely for
this client. Findings of spontaneous eye opening (a 4 on the scale for eye opening, the
maximum score) or orientation to time, place, and person (a 5 for verbal response and
also the maximum score for that component) are unlikely. An assessment finding of
withdraws to touch would be more typical of an infant or young child, not an adult, and
would be a 5 out of 6 for motor response.
QUESTION 3
A school-age client is experiencing photophobia, a sore neck, chills, and fever. During a
physical assessment, the nurse uses the technique in the Exhibit. Why did the nurse use this
technique when assessing the client? (See image.)
A. It is a routine part of the physical assessment.
B. Flexion of the hips or knees would be consistent with meningitis.
C. The nurse was assessing range of motion of the neck.
D. This technique assesses optic nerve functioning.
Correct Answer: B
Rationale: The client's manifestations of a sore neck, chills, fever, and photophobia are
consistent with meningitis. Assessing for the Brudzinski sign can rule in meningitis
because flexing the client's head to the chest will trigger flexion of the hips and knees in
clients with meningeal irritation. Assessing for the Brudzinski sign is not a routine part of
the physical assessment. This maneuver is not done to assess for neck range of motion or
optic nerve functioning.
QUESTION 4
The nurse is reviewing results of diagnostic testing performed on a client with increased
intracranial pressure (ICP) in preparation for an evaluation to be done by the healthcare
provider during morning rounds. Which diagnostic test results should the nurse make available
to the healthcare provider for review? (Select all that apply.)
A. Bronchoscopy results
B. MRI result
,C. Head CT scan with and without contrast
D. Electroencephalogram
E. Cerebrospinal fluid differential cell count
Correct Answer: B, C, D, E
Rationale: Diagnosis of increased ICP is made on the basis of observation and neurologic
assessment; even subtle changes can be clinically significant. Testing can include CT scan
with and without contrast, MRI, electroencephalogram, and cerebrospinal fluid
evaluation. Bronchoscopy is not performed routinely for a client with increased
intracranial pressure.
QUESTION 5
The nurse is determining ways to decrease environmental stimuli for a client with increased
intracranial pressure. Which actions should the nurse take to support this client's care need?
(Select all that apply.)
A. Limit the client's visitors.
B. Teach family to speak softly and minimize touching.
C. Elevate the head of the bed.
D. Raise pads and bedrails.
E. Keep the room dark and quiet.
Correct Answer: A, B, E
Rationale: A dark, quiet room is important to reduce stimuli. Family members should be
encouraged to talk to the client in a soft voice with minimal touching. Visitors should be
limited. Elevating the head of the bed is important to reducing intracranial pressure but
has no effect on stimulation. Raising pads and bedrails is important because of the
possibility of seizures but does not relate to stimulation.
QUESTION 6
The nurse is planning care for an older adult client with a head injury secondary to a motor
vehicle crash. Which information should the nurse keep in mind when planning this client's
care? (Select all that apply.)
A. Anxiety, illness, and pain can alter the ability to learn.
B. Baseline reflexes may be slower or diminished.
C. Impulse transmission and reactions to stimuli are slower.
D. Neurologic assessment should be completed in a single session.
E. Impairment in vision and hearing should be taken into consideration.
Correct Answer: A, B, C, E
Rationale: For an older client, full neurologic assessment can be lengthy. Conduct the
assessment in several sessions if indicated, and cease the tests if the client is noticeably
fatigued. In the older client, anxiety, illness, and pain can alter the ability to learn.
Reflexes may be slower or diminished in an older client. Responses to stimuli are slower
because of reduced impulse transmission. Many older adults have some impairment of
hearing and vision, which should be taken into consideration when planning care.
, QUESTION 7
A client with a head injury is demonstrating signs of increased intracranial pressure (IICP).
Which classifications of medications should the nurse anticipate administering to this client?
(Select all that apply.)
A. Loop diuretics
B. Antibiotics
C. Antiseizure drugs
D. Histamine H2 antagonists
E. Antipyretics
Correct Answer: A, C, D, E
Rationale: Medications play an important role in the management of IICP. Loop
diuretics are commonly used to reduce ICP. Antipyretics such as acetaminophen are used
alone or in combination with a hypothermia blanket to treat hyperthermia. Antiseizure
drugs are often required to manage seizure activity associated with brain injury and
IICP. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists is often
used because clients with IICP are at increased risk for developing stress gastritis and
ulcers. Antibiotics are not routinely prescribed as treatment for IICP.
QUESTION 8
A nurse is performing a neurologic assessment on a 9-year-old child who has displayed
unexplained changes in behavior. Which assessment finding is consistent with a neurologic
deficit?
A. Child has a negative Babinski reflex.
B. Child recalls names of well-known cartoon characters.
C. Child is able to walk backward heel to toe.
D. Child is incapable of balancing on one foot.
Correct Answer: D
Rationale: Children should be able to walk backward by 2 years of age, balance on one
foot for 5 seconds by 4 years of age, heel-toe walk by 5 years of age, and heel-toe walk
backward by 6 years of age. A positive Babinski reflex is abnormal after the child
ambulates or reaches 2 years of age. Ability to recall names of well-known cartoon
characters would show a normal level of recall.
QUESTION 9
What part of the body controls reflexes and regulates activities such as vomiting, hiccupping,
coughing, and sneezing?
A. Brainstem
B. Hypothalamus
C. Spinal cord
D. Thalamus
