NUR 254 Exam 3 Actual Exam 2026/2027 – Complete Exam-Style Questions with
Detailed Rationales | 100% Verified | Pass Guaranteed – A+ Graded
Section A: Neurological Disorders - Assessment, Diagnostics, &
Management
Q1: A patient with a traumatic brain injury presents with hypertension, bradycardia, and
irregular respirations. The nurse recognizes this triad as indicative of:
A. Meningeal irritation
B. Cushing's triad [CORRECT]
C. Autonomic dysreflexia
D. Cluster headache syndrome
Correct Answer: B
Rationale: Cushing's triad (hypertension, bradycardia, irregular respirations) is a late
sign of increased intracranial pressure (ICP) indicating brainstem compression. It
results from the Monro-Kellie doctrine where increased cranial volume compresses the
brainstem. Meningeal irritation presents with nuchal rigidity and photophobia.
Autonomic dysreflexia presents with severe hypertension and headache in spinal cord
injury. Cluster headaches cause unilateral orbital pain with autonomic symptoms but
not this specific triad.
Q2: A patient with increased ICP is being managed in the ICU. Which nursing
intervention is the priority?
,A. Maintain the head of bed flat to maximize cerebral perfusion
B. Elevate the head of bed to 30 degrees [CORRECT]
C. Encourage the patient to perform Valsalva maneuvers
D. Administer hypotonic saline to reduce cerebral edema
Correct Answer: B
Rationale: Elevating the HOB to 30 degrees promotes venous drainage from the brain,
reducing ICP while maintaining cerebral perfusion pressure (CPP). Flat positioning
impairs venous return. Valsalva maneuvers increase ICP. Hypotonic saline worsens
cerebral edema; hypertonic saline or mannitol is used for osmotic therapy.
Q3: A patient with a stroke presents with left-sided facial droop, left arm drift, and
slurred speech. Using the FAST assessment, the nurse recognizes the "A" represents:
A. Alertness
B. Arm drift [CORRECT]
C. Assessment
D. Airway
Correct Answer: B
Rationale: FAST stands for Face drooping, Arm drift, Speech difficulty, and Time to call
emergency services. Arm drift is assessed by having the patient hold both arms
outstretched; weakness causes one arm to drift downward. Alertness, assessment, and
airway are not components of the FAST acronym.
, Q4: A patient with an ischemic stroke is admitted 2 hours after symptom onset. The
nurse anticipates which intervention as the priority?
A. Immediate administration of tissue plasminogen activator (tPA) [CORRECT]
B. Administration of anticoagulant therapy only
C. Surgical evacuation of hematoma
D. Blood pressure elevation to 180/110 mmHg
Correct Answer: A
Rationale: tPA is the gold standard for acute ischemic stroke when administered within
3-4.5 hours of symptom onset, provided there are no contraindications. Anticoagulants
are not first-line for acute ischemic stroke. Surgical evacuation is for hemorrhagic
stroke. Blood pressure is managed cautiously; tPA requires BP <185/110 mmHg.
Q5: A patient with a hemorrhagic stroke is admitted. Which nursing intervention is the
priority?
A. Administer tPA immediately
B. Maintain head of bed at 30 degrees and manage blood pressure [CORRECT]
C. Encourage aggressive range of motion exercises
D. Administer aspirin for stroke prevention
Correct Answer: B
Rationale: Hemorrhagic stroke management focuses on preventing further bleeding by
controlling blood pressure and maintaining HOB at 30 degrees to reduce ICP. tPA is
Detailed Rationales | 100% Verified | Pass Guaranteed – A+ Graded
Section A: Neurological Disorders - Assessment, Diagnostics, &
Management
Q1: A patient with a traumatic brain injury presents with hypertension, bradycardia, and
irregular respirations. The nurse recognizes this triad as indicative of:
A. Meningeal irritation
B. Cushing's triad [CORRECT]
C. Autonomic dysreflexia
D. Cluster headache syndrome
Correct Answer: B
Rationale: Cushing's triad (hypertension, bradycardia, irregular respirations) is a late
sign of increased intracranial pressure (ICP) indicating brainstem compression. It
results from the Monro-Kellie doctrine where increased cranial volume compresses the
brainstem. Meningeal irritation presents with nuchal rigidity and photophobia.
Autonomic dysreflexia presents with severe hypertension and headache in spinal cord
injury. Cluster headaches cause unilateral orbital pain with autonomic symptoms but
not this specific triad.
Q2: A patient with increased ICP is being managed in the ICU. Which nursing
intervention is the priority?
,A. Maintain the head of bed flat to maximize cerebral perfusion
B. Elevate the head of bed to 30 degrees [CORRECT]
C. Encourage the patient to perform Valsalva maneuvers
D. Administer hypotonic saline to reduce cerebral edema
Correct Answer: B
Rationale: Elevating the HOB to 30 degrees promotes venous drainage from the brain,
reducing ICP while maintaining cerebral perfusion pressure (CPP). Flat positioning
impairs venous return. Valsalva maneuvers increase ICP. Hypotonic saline worsens
cerebral edema; hypertonic saline or mannitol is used for osmotic therapy.
Q3: A patient with a stroke presents with left-sided facial droop, left arm drift, and
slurred speech. Using the FAST assessment, the nurse recognizes the "A" represents:
A. Alertness
B. Arm drift [CORRECT]
C. Assessment
D. Airway
Correct Answer: B
Rationale: FAST stands for Face drooping, Arm drift, Speech difficulty, and Time to call
emergency services. Arm drift is assessed by having the patient hold both arms
outstretched; weakness causes one arm to drift downward. Alertness, assessment, and
airway are not components of the FAST acronym.
, Q4: A patient with an ischemic stroke is admitted 2 hours after symptom onset. The
nurse anticipates which intervention as the priority?
A. Immediate administration of tissue plasminogen activator (tPA) [CORRECT]
B. Administration of anticoagulant therapy only
C. Surgical evacuation of hematoma
D. Blood pressure elevation to 180/110 mmHg
Correct Answer: A
Rationale: tPA is the gold standard for acute ischemic stroke when administered within
3-4.5 hours of symptom onset, provided there are no contraindications. Anticoagulants
are not first-line for acute ischemic stroke. Surgical evacuation is for hemorrhagic
stroke. Blood pressure is managed cautiously; tPA requires BP <185/110 mmHg.
Q5: A patient with a hemorrhagic stroke is admitted. Which nursing intervention is the
priority?
A. Administer tPA immediately
B. Maintain head of bed at 30 degrees and manage blood pressure [CORRECT]
C. Encourage aggressive range of motion exercises
D. Administer aspirin for stroke prevention
Correct Answer: B
Rationale: Hemorrhagic stroke management focuses on preventing further bleeding by
controlling blood pressure and maintaining HOB at 30 degrees to reduce ICP. tPA is
