NSG 4100 Exam 4 Final with questions and well
verified answers real exam Advanced Concepts in
Complex Care
2025/2026 Academic Year
Section 1: Neurological Conditions & Increased Intracranial Pressure (ICP) (Questions 1-25)
1. A nurse is caring for a client with a traumatic brain injury. Which of the following assessment
findings should the nurse identify as the earliest sign of increased intracranial pressure (ICP)?
A. Widened pulse pressure and bradycardia
B. Non-purposeful movement and decorticate posturing
C. Restlessness and a change in level of consciousness
D. Projectile vomiting and papilledema
[Answer: C]
A change in LOC, such as restlessness, confusion, or drowsiness, is the most sensitive and earliest
indicator of increased ICP .
2. A client is admitted to the ICU with an epidural hematoma following a fall. The nurse anticipates
preparing the client for which emergency procedure?
A. Administration of tissue plasminogen activator (tPA)
B. Burr holes to evacuate the hematoma
C. A lumbar puncture to drain cerebrospinal fluid
D. Initiation of a hypothermia protocol
[Answer: B]
An epidural hematoma is a surgical emergency requiring evacuation, often via burr holes or craniotomy,
to prevent fatal herniation .
3. The nurse is calculating cerebral perfusion pressure (CPP) for a client with a head injury. The client's
blood pressure is 136/82 mmHg, and the ICP is 18 mmHg. What is the client's CPP?
A. 54 mmHg
B. 64 mmHg
C. 74 mmHg
D. 84 mmHg
[Answer: C]
*CPP is calculated as Mean Arterial Pressure (MAP) minus ICP. MAP = [SBP + 2(DBP)]/3 = [136 + 2(82)]/3
= 100 mmHg. CPP = 100 - 18 = 74 mmHg. Normal CPP is 60-100 mmHg .*
4. A client with a subdural hematoma develops Cushing's Triad. Which vital sign findings would the
nurse expect to observe?
,A. Tachycardia, tachypnea, and narrowing pulse pressure
B. Bradycardia, bradypnea, and widening pulse pressure
C. Atrial fibrillation, Cheyne-Stokes respirations, and hypotension
D. Hyperthermia, bradypnea, and hypotension
[Answer: B]
Cushing's Triad is a late sign of severely increased ICP and consists of hypertension (with a widening
pulse pressure), bradycardia, and bradypnea .
5. Which of the following clients on the neuro unit is most at risk for developing diabetes insipidus
(DI)?
A. A client with a stroke in the temporal lobe
B. A client undergoing a craniotomy for a pituitary tumor
C. A client with bacterial meningitis on droplet precautions
D. A client with a C2 spinal cord injury
[Answer: B]
DI is often caused by a deficiency of antidiuretic hormone (ADH). This can occur from damage to the
pituitary gland or hypothalamus, such as during pituitary surgery (hypophysectomy) or from severe head
trauma .
6. The nurse is caring for a client post-craniotomy. The client's urine output has been 800 mL for the
first 4 hours of the shift. The nurse's next action should be to:
A. Document this as an expected finding.
B. Assess the client's specific gravity and notify the provider.
C. Restrict the client's oral fluid intake.
D. Administer a dose of desmopressin (DDAVP) as a standing order.
[Answer: B]
*High urine output (>200 mL/hr) post-craniotomy is a sign of DI. The nurse should assess the urine
specific gravity (which will be low) and notify the provider for further orders .*
7. A client with a severe closed head injury is intubated and mechanically ventilated. Which
intervention is most important to include in the plan of care to reduce the risk of increasing ICP?
A. Suction the endotracheal tube every hour to maintain patency.
B. Maintain the head of the bed (HOB) at 30-45 degrees.
C. Position the client in a flat, supine position to promote venous return.
D. Cluster all nursing care to allow for long rest periods.
[Answer: B]
*Elevating the HOB to 30-45 degrees promotes venous drainage from the brain, which helps lower ICP .
Suctioning should be done only when needed, not routinely, as it can spike ICP. Care should be clustered
to prevent stimulation, but not at the expense of overwhelming the client.*
8. The nurse assesses a client and finds them to be unresponsive to voice, with decerebrate posturing
to painful stimulation. How should the nurse document the client's Glasgow Coma Scale (GCS) score
for the motor response?
A. Motor response 3
B. Motor response 4
C. Motor response 5
, D. Motor response 2
[Answer: D]
On the GCS, decerebrate posturing (extension) is a motor score of 2. Decorticate (flexion) is a score of 3 .
9. A client is prescribed mannitol (Osmitrol) for management of increased ICP. Which assessment
finding indicates the medication is having the desired therapeutic effect?
A. A decrease in serum osmolality
B. A decrease in ICP and an increase in CPP
C. An increase in central venous pressure (CVP)
D. A decrease in urine output
[Answer: B]
Mannitol is an osmotic diuretic that works by drawing fluid from the brain tissue into the vascular space,
which reduces cerebral edema and ICP. The goal is to see a reduction in ICP and improvement in CPP .
10. A client is admitted with suspected bacterial meningitis. Which assessment finding would the
nurse anticipate?
A. Flaccid paralysis and areflexia
B. Dysphagia and scanning speech
C. Nuchal rigidity and photophobia
D. Ascending weakness and respiratory failure
[Answer: C]
Classic signs of meningitis include nuchal rigidity (stiff neck), photophobia (sensitivity to light), fever, and
severe headache .
11. A client with encephalitis is admitted to the unit. Which nursing intervention is most appropriate
for this client?
A. Keeping the room dark and quiet to minimize stimulation
B. Placing the client on droplet precautions
C. Encouraging family members to stay at the bedside to orient the client
D. Applying warm compresses to relieve a severe headache
[Answer: A]
Clients with encephalitis have cerebral inflammation and are at risk for seizures and increased ICP.
Minimizing environmental stimuli (dim lights, quiet environment, clustering care) helps reduce cerebral
metabolic demands and the risk of seizures .
12. A client who is post-operative day 1 from a craniotomy reports a "runny nose." What is the nurse's
priority action?
A. Provide the client with tissues and encourage rest.
B. Administer a prescribed decongestant.
C. Test the drainage for glucose and protein.
D. Document the finding as a normal post-operative occurrence.
[Answer: C]
Rhinorrhea post-craniotomy could be cerebrospinal fluid (CSF) leakage. CSF is positive for glucose and
protein. The drainage must be tested to rule out a CSF leak, which poses a high risk for meningitis .
13. A client with a T4 spinal cord injury suddenly develops a severe, throading headache, diaphoresis
above the level of injury, and a BP of 210/110 mmHg. The client's bladder is distended. After elevating
verified answers real exam Advanced Concepts in
Complex Care
2025/2026 Academic Year
Section 1: Neurological Conditions & Increased Intracranial Pressure (ICP) (Questions 1-25)
1. A nurse is caring for a client with a traumatic brain injury. Which of the following assessment
findings should the nurse identify as the earliest sign of increased intracranial pressure (ICP)?
A. Widened pulse pressure and bradycardia
B. Non-purposeful movement and decorticate posturing
C. Restlessness and a change in level of consciousness
D. Projectile vomiting and papilledema
[Answer: C]
A change in LOC, such as restlessness, confusion, or drowsiness, is the most sensitive and earliest
indicator of increased ICP .
2. A client is admitted to the ICU with an epidural hematoma following a fall. The nurse anticipates
preparing the client for which emergency procedure?
A. Administration of tissue plasminogen activator (tPA)
B. Burr holes to evacuate the hematoma
C. A lumbar puncture to drain cerebrospinal fluid
D. Initiation of a hypothermia protocol
[Answer: B]
An epidural hematoma is a surgical emergency requiring evacuation, often via burr holes or craniotomy,
to prevent fatal herniation .
3. The nurse is calculating cerebral perfusion pressure (CPP) for a client with a head injury. The client's
blood pressure is 136/82 mmHg, and the ICP is 18 mmHg. What is the client's CPP?
A. 54 mmHg
B. 64 mmHg
C. 74 mmHg
D. 84 mmHg
[Answer: C]
*CPP is calculated as Mean Arterial Pressure (MAP) minus ICP. MAP = [SBP + 2(DBP)]/3 = [136 + 2(82)]/3
= 100 mmHg. CPP = 100 - 18 = 74 mmHg. Normal CPP is 60-100 mmHg .*
4. A client with a subdural hematoma develops Cushing's Triad. Which vital sign findings would the
nurse expect to observe?
,A. Tachycardia, tachypnea, and narrowing pulse pressure
B. Bradycardia, bradypnea, and widening pulse pressure
C. Atrial fibrillation, Cheyne-Stokes respirations, and hypotension
D. Hyperthermia, bradypnea, and hypotension
[Answer: B]
Cushing's Triad is a late sign of severely increased ICP and consists of hypertension (with a widening
pulse pressure), bradycardia, and bradypnea .
5. Which of the following clients on the neuro unit is most at risk for developing diabetes insipidus
(DI)?
A. A client with a stroke in the temporal lobe
B. A client undergoing a craniotomy for a pituitary tumor
C. A client with bacterial meningitis on droplet precautions
D. A client with a C2 spinal cord injury
[Answer: B]
DI is often caused by a deficiency of antidiuretic hormone (ADH). This can occur from damage to the
pituitary gland or hypothalamus, such as during pituitary surgery (hypophysectomy) or from severe head
trauma .
6. The nurse is caring for a client post-craniotomy. The client's urine output has been 800 mL for the
first 4 hours of the shift. The nurse's next action should be to:
A. Document this as an expected finding.
B. Assess the client's specific gravity and notify the provider.
C. Restrict the client's oral fluid intake.
D. Administer a dose of desmopressin (DDAVP) as a standing order.
[Answer: B]
*High urine output (>200 mL/hr) post-craniotomy is a sign of DI. The nurse should assess the urine
specific gravity (which will be low) and notify the provider for further orders .*
7. A client with a severe closed head injury is intubated and mechanically ventilated. Which
intervention is most important to include in the plan of care to reduce the risk of increasing ICP?
A. Suction the endotracheal tube every hour to maintain patency.
B. Maintain the head of the bed (HOB) at 30-45 degrees.
C. Position the client in a flat, supine position to promote venous return.
D. Cluster all nursing care to allow for long rest periods.
[Answer: B]
*Elevating the HOB to 30-45 degrees promotes venous drainage from the brain, which helps lower ICP .
Suctioning should be done only when needed, not routinely, as it can spike ICP. Care should be clustered
to prevent stimulation, but not at the expense of overwhelming the client.*
8. The nurse assesses a client and finds them to be unresponsive to voice, with decerebrate posturing
to painful stimulation. How should the nurse document the client's Glasgow Coma Scale (GCS) score
for the motor response?
A. Motor response 3
B. Motor response 4
C. Motor response 5
, D. Motor response 2
[Answer: D]
On the GCS, decerebrate posturing (extension) is a motor score of 2. Decorticate (flexion) is a score of 3 .
9. A client is prescribed mannitol (Osmitrol) for management of increased ICP. Which assessment
finding indicates the medication is having the desired therapeutic effect?
A. A decrease in serum osmolality
B. A decrease in ICP and an increase in CPP
C. An increase in central venous pressure (CVP)
D. A decrease in urine output
[Answer: B]
Mannitol is an osmotic diuretic that works by drawing fluid from the brain tissue into the vascular space,
which reduces cerebral edema and ICP. The goal is to see a reduction in ICP and improvement in CPP .
10. A client is admitted with suspected bacterial meningitis. Which assessment finding would the
nurse anticipate?
A. Flaccid paralysis and areflexia
B. Dysphagia and scanning speech
C. Nuchal rigidity and photophobia
D. Ascending weakness and respiratory failure
[Answer: C]
Classic signs of meningitis include nuchal rigidity (stiff neck), photophobia (sensitivity to light), fever, and
severe headache .
11. A client with encephalitis is admitted to the unit. Which nursing intervention is most appropriate
for this client?
A. Keeping the room dark and quiet to minimize stimulation
B. Placing the client on droplet precautions
C. Encouraging family members to stay at the bedside to orient the client
D. Applying warm compresses to relieve a severe headache
[Answer: A]
Clients with encephalitis have cerebral inflammation and are at risk for seizures and increased ICP.
Minimizing environmental stimuli (dim lights, quiet environment, clustering care) helps reduce cerebral
metabolic demands and the risk of seizures .
12. A client who is post-operative day 1 from a craniotomy reports a "runny nose." What is the nurse's
priority action?
A. Provide the client with tissues and encourage rest.
B. Administer a prescribed decongestant.
C. Test the drainage for glucose and protein.
D. Document the finding as a normal post-operative occurrence.
[Answer: C]
Rhinorrhea post-craniotomy could be cerebrospinal fluid (CSF) leakage. CSF is positive for glucose and
protein. The drainage must be tested to rule out a CSF leak, which poses a high risk for meningitis .
13. A client with a T4 spinal cord injury suddenly develops a severe, throading headache, diaphoresis
above the level of injury, and a BP of 210/110 mmHg. The client's bladder is distended. After elevating
