NSG430 Exam 3 V2 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with a traumatic brain injury who is showing signs of
increased intracranial pressure (ICP). Which of the following is the earliest indicator of a
change in neurological status?
A. A change in the level of consciousness
B. Dilation of the pupils
C. The presence of Cushing’s triad
D. Decerebrate posturing
Answer: A
Rationale: A change in the level of consciousness (LOC) is considered the most sensitive
and earliest sign of increased intracranial pressure. This occurs because the brain’s cortical
cells are highly sensitive to decreased oxygen and glucose delivery caused by rising
pressure. Nurses must assess for subtle changes such as restlessness, confusion, or
increased lethargy to intervene early.
2. A patient with a spinal cord injury at the T4 level reports a sudden, severe headache and is
found to have a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Sit the patient upright immediately
B. Check the patient’s temperature
,C. Administer an antihypertensive medication
D. Perform a digital rectal exam to check for impaction
Answer: A
Rationale: The patient is demonstrating signs of autonomic dysreflexia, which is a medical
emergency common in injuries at T6 or above. Sitting the patient upright is the first action
because it utilizes orthostatic hypotension to help lower the dangerously high blood
pressure. Following this, the nurse should assess for the triggering cause, such as a
distended bladder or bowel impaction.
3. A nurse is preparing to administer Mannitol (Osmitrol) to a patient with increased ICP.
Which assessment is most important to monitor the effectiveness of this medication?
A. Blood glucose levels
B. Increased urine output
C. Decreased body temperature
D. Deep tendon reflexes
Answer: B
Rationale: Mannitol is an osmotic diuretic that works by drawing fluid out of the brain
tissue and into the vascular space to reduce cerebral edema. Because it is a diuretic, the
effectiveness is evidenced by an increase in urine output and a subsequent decrease in
intracranial pressure. The nurse should also monitor serum osmolality and electrolytes
during administration.
, 4. A patient who underwent a total hip arthroplasty (THA) is being positioned in bed. Which
intervention should the nurse implement to prevent dislocation of the prosthesis?
A. Maintain the legs in an adducted position
B. Place an abduction pillow between the legs
C. Keep the hip flexed at a 90-degree angle
D. Turn the patient onto the operative side
Answer: B
Rationale: Following a total hip arthroplasty, it is critical to keep the operative leg in an
abducted position to prevent the femoral head from popping out of the acetabulum. An
abduction pillow or wedge is used to ensure the legs do not cross the midline. Patients
should also avoid flexing the hip more than 90 degrees to maintain joint stability.
5. During a blood transfusion, a patient begins to complain of back pain, chills, and shortness
of breath. After stopping the infusion, what is the next priority action for the nurse?
A. Notify the healthcare provider immediately
B. Infuse normal saline through new IV tubing
C. Return the blood bag to the blood bank
D. Document the reaction in the medical record
Answer: B
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with a traumatic brain injury who is showing signs of
increased intracranial pressure (ICP). Which of the following is the earliest indicator of a
change in neurological status?
A. A change in the level of consciousness
B. Dilation of the pupils
C. The presence of Cushing’s triad
D. Decerebrate posturing
Answer: A
Rationale: A change in the level of consciousness (LOC) is considered the most sensitive
and earliest sign of increased intracranial pressure. This occurs because the brain’s cortical
cells are highly sensitive to decreased oxygen and glucose delivery caused by rising
pressure. Nurses must assess for subtle changes such as restlessness, confusion, or
increased lethargy to intervene early.
2. A patient with a spinal cord injury at the T4 level reports a sudden, severe headache and is
found to have a blood pressure of 190/100 mmHg. What is the priority nursing action?
A. Sit the patient upright immediately
B. Check the patient’s temperature
,C. Administer an antihypertensive medication
D. Perform a digital rectal exam to check for impaction
Answer: A
Rationale: The patient is demonstrating signs of autonomic dysreflexia, which is a medical
emergency common in injuries at T6 or above. Sitting the patient upright is the first action
because it utilizes orthostatic hypotension to help lower the dangerously high blood
pressure. Following this, the nurse should assess for the triggering cause, such as a
distended bladder or bowel impaction.
3. A nurse is preparing to administer Mannitol (Osmitrol) to a patient with increased ICP.
Which assessment is most important to monitor the effectiveness of this medication?
A. Blood glucose levels
B. Increased urine output
C. Decreased body temperature
D. Deep tendon reflexes
Answer: B
Rationale: Mannitol is an osmotic diuretic that works by drawing fluid out of the brain
tissue and into the vascular space to reduce cerebral edema. Because it is a diuretic, the
effectiveness is evidenced by an increase in urine output and a subsequent decrease in
intracranial pressure. The nurse should also monitor serum osmolality and electrolytes
during administration.
, 4. A patient who underwent a total hip arthroplasty (THA) is being positioned in bed. Which
intervention should the nurse implement to prevent dislocation of the prosthesis?
A. Maintain the legs in an adducted position
B. Place an abduction pillow between the legs
C. Keep the hip flexed at a 90-degree angle
D. Turn the patient onto the operative side
Answer: B
Rationale: Following a total hip arthroplasty, it is critical to keep the operative leg in an
abducted position to prevent the femoral head from popping out of the acetabulum. An
abduction pillow or wedge is used to ensure the legs do not cross the midline. Patients
should also avoid flexing the hip more than 90 degrees to maintain joint stability.
5. During a blood transfusion, a patient begins to complain of back pain, chills, and shortness
of breath. After stopping the infusion, what is the next priority action for the nurse?
A. Notify the healthcare provider immediately
B. Infuse normal saline through new IV tubing
C. Return the blood bag to the blood bank
D. Document the reaction in the medical record
Answer: B
