NUR 417 Final Exam Questions & Answers 2026 | Latest
Review Guide
1. A patient who is unconscious after a head injury has cerebral edema. Which
nursing intervention will be included in the plan of care?
Position the patient with knees and hips flexed.
Cluster nursing interventions to provide rest periods.
Encourage coughing and deep breathing.
Keep the head of the bed elevated to 30 degrees.
2. What is the significance of a pupil that is 10 mm and unresponsive to light in a
patient with a head injury?
It indicates a concussion.
It suggests a minor head injury.
It indicates potential severe neurological impairment.
It is a normal finding in head injuries.
3. A patient has a nursing diagnosis of ineffective tissue perfusion related to
cerebral tissue swelling. An appropriate nursing intervention for this problem
is to:
Provide a position of comfort with knees and hips flexed
Teach the patient to cough and deep breathe to prevent the necessity
for suctioning
Elevate HOB by 30 degrees
Place in the supine position to allow venous flow.
,4. In a scenario where a patient with increased intracranial pressure is
experiencing worsening symptoms, what nursing intervention should be
prioritized?
Contact the physician for immediate intervention.
Administer pain medication immediately.
Perform a full neurological assessment.
Elevate the head of the bed to 30 degrees.
5. When the nurse applies a painful stimulus to the nailbeds of an unconscious
patient, the patient responds with internal rotation, adduction, and flexion of
the arms. The nurse documents this as
decorticate posturing.
localization of pain.
decerebrate posturing.
flexion withdrawal.
6. The emergency nurses caring for a patient with increased intracranial
pressure following a traumatic head injury. Which of the following vital signs
should the nurse immediately report to the physician?
mean arterial pressure 70
capnography of 30
heart rate 94 beats per minute
temperature 101.3° f
,7. The nurse is assessing a client with bacterial meningitis and obtains the
following data. Which of the following findings should be reported
immediately to the health care provider?
The client's blood pressure is 86/42 mm Hg.
The client has a positive Kernig's sign.
The client's temperature is 38.3C (100.9F).
The client complains of having a stiff neck.
8. A college athlete is seen in the clinic 6 weeks after a concussion. Which
assessment information will the nurse collect to determine whether the
patient is developing post-concussion syndrome?
Muscle coordination
Glasgow Coma Scale
Pupil reaction to light
Short-term memory
9. In a scenario where a patient with a GCS score of 7 shows signs of increased
intracranial pressure (ICP), what immediate nursing intervention should be
prioritized?
Perform a full neurological assessment without reporting.
Notify the physician for further evaluation and intervention.
Increase the patient's fluid intake.
Administer pain medication to the patient.
, 10. If the nurse assesses the 50-year-old patient with the unresponsive pupil and
finds that the intracranial pressure is elevated, what should be the immediate
nursing intervention?
Notify the physician and prepare for potential surgical intervention.
Place the patient in a supine position.
Reassess the Glasgow Coma Scale score.
Administer pain medication to the patient.
11. The patient is scheduled to receive levothyroxine (Synthroid). Which of the
following assessments would indicate the nurse should hold the medication?
Patient is NPO except for meds.
Patient's heart rate is 114 bpm.
Patient's glucose is 110 mg/dL.
Patient's blood pressure is 110/60.
12. A patient is admitted to the ED after a car accident resulting in head trauma,
the nurse knows to look for what initial sign of potential increased cranial
pressure (ICP)?
Decreased level of consciousness
Cushing's triad
Projectile vomiting
Fever
13. Describe the significance of Cushing's triad in relation to increased
intracranial pressure (ICP).
Review Guide
1. A patient who is unconscious after a head injury has cerebral edema. Which
nursing intervention will be included in the plan of care?
Position the patient with knees and hips flexed.
Cluster nursing interventions to provide rest periods.
Encourage coughing and deep breathing.
Keep the head of the bed elevated to 30 degrees.
2. What is the significance of a pupil that is 10 mm and unresponsive to light in a
patient with a head injury?
It indicates a concussion.
It suggests a minor head injury.
It indicates potential severe neurological impairment.
It is a normal finding in head injuries.
3. A patient has a nursing diagnosis of ineffective tissue perfusion related to
cerebral tissue swelling. An appropriate nursing intervention for this problem
is to:
Provide a position of comfort with knees and hips flexed
Teach the patient to cough and deep breathe to prevent the necessity
for suctioning
Elevate HOB by 30 degrees
Place in the supine position to allow venous flow.
,4. In a scenario where a patient with increased intracranial pressure is
experiencing worsening symptoms, what nursing intervention should be
prioritized?
Contact the physician for immediate intervention.
Administer pain medication immediately.
Perform a full neurological assessment.
Elevate the head of the bed to 30 degrees.
5. When the nurse applies a painful stimulus to the nailbeds of an unconscious
patient, the patient responds with internal rotation, adduction, and flexion of
the arms. The nurse documents this as
decorticate posturing.
localization of pain.
decerebrate posturing.
flexion withdrawal.
6. The emergency nurses caring for a patient with increased intracranial
pressure following a traumatic head injury. Which of the following vital signs
should the nurse immediately report to the physician?
mean arterial pressure 70
capnography of 30
heart rate 94 beats per minute
temperature 101.3° f
,7. The nurse is assessing a client with bacterial meningitis and obtains the
following data. Which of the following findings should be reported
immediately to the health care provider?
The client's blood pressure is 86/42 mm Hg.
The client has a positive Kernig's sign.
The client's temperature is 38.3C (100.9F).
The client complains of having a stiff neck.
8. A college athlete is seen in the clinic 6 weeks after a concussion. Which
assessment information will the nurse collect to determine whether the
patient is developing post-concussion syndrome?
Muscle coordination
Glasgow Coma Scale
Pupil reaction to light
Short-term memory
9. In a scenario where a patient with a GCS score of 7 shows signs of increased
intracranial pressure (ICP), what immediate nursing intervention should be
prioritized?
Perform a full neurological assessment without reporting.
Notify the physician for further evaluation and intervention.
Increase the patient's fluid intake.
Administer pain medication to the patient.
, 10. If the nurse assesses the 50-year-old patient with the unresponsive pupil and
finds that the intracranial pressure is elevated, what should be the immediate
nursing intervention?
Notify the physician and prepare for potential surgical intervention.
Place the patient in a supine position.
Reassess the Glasgow Coma Scale score.
Administer pain medication to the patient.
11. The patient is scheduled to receive levothyroxine (Synthroid). Which of the
following assessments would indicate the nurse should hold the medication?
Patient is NPO except for meds.
Patient's heart rate is 114 bpm.
Patient's glucose is 110 mg/dL.
Patient's blood pressure is 110/60.
12. A patient is admitted to the ED after a car accident resulting in head trauma,
the nurse knows to look for what initial sign of potential increased cranial
pressure (ICP)?
Decreased level of consciousness
Cushing's triad
Projectile vomiting
Fever
13. Describe the significance of Cushing's triad in relation to increased
intracranial pressure (ICP).
