Rasmussen University NUR 2755 Exam 1 (pdf) | 2026/2027 | MDC 4
Q&A | Nursing
1. The nurse is caring for a client with a head injury. Which assessment
finding is the earliest and most sensitive indicator of a change in the client's
neurologic status?
A) Pupillary response
B) Level of consciousness
C) Motor strength
D) Vital signs
Correct Answer: Level of consciousness
Rationale: Level of consciousness (LOC) is the most sensitive indicator of
neurologic change. Changes in LOC, such as restlessness, confusion, or
lethargy, are often the earliest signs of deterioration. Pupillary changes,
motor findings, and vital signs are important but typically occur later or
indicate more specific deficits. Trends in LOC over time are critical for guiding
interventions.
2. A client with a head injury has a blood pressure of 180/90 mm Hg, a heart
rate of 50 beats per minute, and irregular respirations. The nurse should
recognize this as:
A) Early signs of increased intracranial pressure
B) Cushing's triad, a late sign of increased intracranial pressure
C) Normal compensatory mechanisms
D) Signs of a stroke
Correct Answer: Cushing's triad, a late sign of increased intracranial pressure
,Rationale: Cushing's triad—increasing systolic blood pressure with widening
pulse pressure, bradycardia, and irregular respirations—is a late sign of
increased ICP indicating impending brain herniation. This is a medical
emergency requiring immediate intervention. Early signs of increased ICP
include changes in LOC, headache, and vomiting.
3. Which nursing intervention is most appropriate to help reduce intracranial
pressure (ICP) in a client with a traumatic brain injury?
A) Keep the head of the bed flat
B) Elevate the head of the bed to 30 degrees
C) Position the client in a prone position
D) Turn the client's head to the side
Correct Answer: Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous
drainage from the head and helps reduce ICP. Keeping the head flat or
turning the head to the side can increase ICP by impairing venous outflow.
The head and neck should be kept in a midline position to facilitate drainage.
4. A client with a brain tumor is at risk for which complication related to the
endocrine system?
A) Hyperthyroidism
B) Diabetes insipidus
C) Hyperglycemia
D) Adrenal insufficiency
Correct Answer: Diabetes insipidus
,Rationale: Brain injury, including tumors affecting the pituitary or
hypothalamus, can disrupt antidiuretic hormone (ADH) production, leading to
diabetes insipidus (DI). DI is characterized by low ADH, large dilute urine
output, dehydration, and hypernatremia. SIADH (syndrome of inappropriate
antidiuretic hormone) is the opposite condition, causing water retention and
hyponatremia.
5. A client with a brain injury is experiencing large volumes of dilute urine,
thirst, and tachycardia. The nurse should suspect which condition?
A) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
B) Diabetes insipidus (DI)
C) Hyperglycemia
D) Cerebral salt wasting
Correct Answer: Diabetes insipidus (DI)
Rationale: Diabetes insipidus (DI) results from low ADH, causing the kidneys
to excrete large amounts of dilute urine. Symptoms include polyuria,
polydipsia (thirst), dehydration, tachycardia, and hypernatremia. SIADH
causes water retention, hyponatremia, and concentrated urine.
6. Which lobe of the brain is primarily responsible for personality, judgment,
and behavior?
A) Frontal lobe
B) Parietal lobe
C) Temporal lobe
D) Occipital lobe
Correct Answer: Frontal lobe
, Rationale: The frontal lobe is responsible for personality, judgment, behavior,
motor function, and expressive speech (Broca's area). Damage to this lobe
can result in behavior changes, impulsivity, poor judgment, weakness, and
expressive aphasia. The parietal lobe is responsible for sensation, the
temporal lobe for hearing and memory, and the occipital lobe for vision.
7. A client has difficulty understanding spoken language and is unable to
follow verbal commands. The nurse suspects damage to which area of the
brain?
A) Broca's area
B) Wernicke's area
C) Primary motor cortex
D) Cerebellum
Correct Answer: Wernicke's area
Rationale: Wernicke's area, located in the temporal lobe, is responsible for
language comprehension. Damage results in receptive aphasia, where the
client has difficulty understanding spoken or written language. Broca's area,
in the frontal lobe, controls expressive speech. The primary motor cortex
controls voluntary movement, and the cerebellum controls coordination.
8. A client who has difficulty with balance and coordination is likely
experiencing damage to which part of the brain?
A) Frontal lobe
B) Temporal lobe
C) Cerebellum
D) Brainstem
Correct Answer: Cerebellum
Q&A | Nursing
1. The nurse is caring for a client with a head injury. Which assessment
finding is the earliest and most sensitive indicator of a change in the client's
neurologic status?
A) Pupillary response
B) Level of consciousness
C) Motor strength
D) Vital signs
Correct Answer: Level of consciousness
Rationale: Level of consciousness (LOC) is the most sensitive indicator of
neurologic change. Changes in LOC, such as restlessness, confusion, or
lethargy, are often the earliest signs of deterioration. Pupillary changes,
motor findings, and vital signs are important but typically occur later or
indicate more specific deficits. Trends in LOC over time are critical for guiding
interventions.
2. A client with a head injury has a blood pressure of 180/90 mm Hg, a heart
rate of 50 beats per minute, and irregular respirations. The nurse should
recognize this as:
A) Early signs of increased intracranial pressure
B) Cushing's triad, a late sign of increased intracranial pressure
C) Normal compensatory mechanisms
D) Signs of a stroke
Correct Answer: Cushing's triad, a late sign of increased intracranial pressure
,Rationale: Cushing's triad—increasing systolic blood pressure with widening
pulse pressure, bradycardia, and irregular respirations—is a late sign of
increased ICP indicating impending brain herniation. This is a medical
emergency requiring immediate intervention. Early signs of increased ICP
include changes in LOC, headache, and vomiting.
3. Which nursing intervention is most appropriate to help reduce intracranial
pressure (ICP) in a client with a traumatic brain injury?
A) Keep the head of the bed flat
B) Elevate the head of the bed to 30 degrees
C) Position the client in a prone position
D) Turn the client's head to the side
Correct Answer: Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous
drainage from the head and helps reduce ICP. Keeping the head flat or
turning the head to the side can increase ICP by impairing venous outflow.
The head and neck should be kept in a midline position to facilitate drainage.
4. A client with a brain tumor is at risk for which complication related to the
endocrine system?
A) Hyperthyroidism
B) Diabetes insipidus
C) Hyperglycemia
D) Adrenal insufficiency
Correct Answer: Diabetes insipidus
,Rationale: Brain injury, including tumors affecting the pituitary or
hypothalamus, can disrupt antidiuretic hormone (ADH) production, leading to
diabetes insipidus (DI). DI is characterized by low ADH, large dilute urine
output, dehydration, and hypernatremia. SIADH (syndrome of inappropriate
antidiuretic hormone) is the opposite condition, causing water retention and
hyponatremia.
5. A client with a brain injury is experiencing large volumes of dilute urine,
thirst, and tachycardia. The nurse should suspect which condition?
A) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
B) Diabetes insipidus (DI)
C) Hyperglycemia
D) Cerebral salt wasting
Correct Answer: Diabetes insipidus (DI)
Rationale: Diabetes insipidus (DI) results from low ADH, causing the kidneys
to excrete large amounts of dilute urine. Symptoms include polyuria,
polydipsia (thirst), dehydration, tachycardia, and hypernatremia. SIADH
causes water retention, hyponatremia, and concentrated urine.
6. Which lobe of the brain is primarily responsible for personality, judgment,
and behavior?
A) Frontal lobe
B) Parietal lobe
C) Temporal lobe
D) Occipital lobe
Correct Answer: Frontal lobe
, Rationale: The frontal lobe is responsible for personality, judgment, behavior,
motor function, and expressive speech (Broca's area). Damage to this lobe
can result in behavior changes, impulsivity, poor judgment, weakness, and
expressive aphasia. The parietal lobe is responsible for sensation, the
temporal lobe for hearing and memory, and the occipital lobe for vision.
7. A client has difficulty understanding spoken language and is unable to
follow verbal commands. The nurse suspects damage to which area of the
brain?
A) Broca's area
B) Wernicke's area
C) Primary motor cortex
D) Cerebellum
Correct Answer: Wernicke's area
Rationale: Wernicke's area, located in the temporal lobe, is responsible for
language comprehension. Damage results in receptive aphasia, where the
client has difficulty understanding spoken or written language. Broca's area,
in the frontal lobe, controls expressive speech. The primary motor cortex
controls voluntary movement, and the cerebellum controls coordination.
8. A client who has difficulty with balance and coordination is likely
experiencing damage to which part of the brain?
A) Frontal lobe
B) Temporal lobe
C) Cerebellum
D) Brainstem
Correct Answer: Cerebellum
