Nur 265 2026/2027 Latest Exam 500
ActualQuestions And Real Reliable
Answers |Already Grade A+ Guaranteed
Pass (Charmberlain School Of Nursing )
Most Recent !!!
Question 1: The nurse is caring for a patient with a traumatic brain injury (TBI). Which finding should the nurse
recognize as the earliest sign of neurologic deterioration?
• A) Fixed pupils
• B) Decreased level of consciousness
• C) Decerebrate posturing
• D) Cushing's triad
Answer: B
Rationale: A change in level of consciousness (LOC) is the earliest indicator of neurologic deterioration and must g
Question 2: A patient has a Glasgow Coma Scale (GCS) score of 6. How should the nurse interpret this finding?
• A) Mild neurologic impairment
• B) Moderate neurologic impairment
• C) Patient is comatose
• D) Normal neurologic status
Answer: C
Rationale: A GCS score of 7 or less indicates coma and reflects severe neurologic dysfunction requiring immediate
intervention.
Question 3: The nurse observes abnormal flexion of the patient's arms, wrists, and fingers with plantar flexion of
the legs. How should this finding be documented?
1|Page SUCCESS!!!
, • A) Decerebrate posturing
• B) Flaccid paralysis
• C) Decorticate posturing
• D) Hemiparesis
Answer: C
Rationale: Decorticate (flexor) posturing is characterized by flexion of the arms, wrists, and fingers with internal
rotation and plantar flexion of the legs.
Question 4: The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury,
is receiving mechanical ventilation, and is at risk for developing ICP. Which action requires intervention by the
charge nurse?
• A) Maintaining the head midline
• B) Elevating the head of the bed to 30 degrees
• C) Raising the foot of the client's bed
• D) Minimizing environmental stimulation
Answer: C
Rationale: The head should be maintained in a midline, neutral position to prevent increased ICP. Raising the foot
of the bed is incorrect and would increase ICP.
Question 5: The newly hired nurse is caring for a client admitted 12 hours ago with a TBI and at risk for ICP.
Which action requires intervention by the nurse preceptor?
• A) Performing frequent neuro checks
• B) Clustering client care activities
• C) Keeping the room quiet and dim
• D) Maintaining HOB at 30 degrees
Answer: B
Rationale: When multiple activities are clustered in a row, the effect on ICP can be a dramatic elevation. Care
should be spaced out to avoid sudden ICP spikes.
Question 6: The nurse is assessing clients for the risk of sustaining a TBI. Which client is at greatest risk?
• A) 65-year-old female with a history of falls
• B) 20-year-old college student who plays football
• C) 45-year-old male construction worker
• D) 72-year-old male with hypertension
2|Page SUCCESS!!!
,Answer: B
Rationale: Young adults aged 15-24 are at highest risk for TBI, particularly athletes in contact sports like football.
A force produced by a blow direct to the head can contribute to brain injury.
Question 7: The nurse caring for assigned clients notes which assessment finding requires notification of the
primary healthcare provider?
• A) Headache rated 4/10
• B) Slight confusion
• C) Asymmetric pupils with no reaction to light
• D) Photophobia
Answer: C
Rationale: Pupillary changes – dilated and non-reactive pupils ("blown" pupils) or constrictive, non-reactive pupils
– indicate neurologic emergency and require immediate notification.
Question 8: The nurse is caring for a client who had a TBI with a skull fracture. The nurse notes the client has
developed rhinorrhea (nasal drip) that is positive for glucose. What action should the nurse take next?
• A) Notify the healthcare provider immediately
• B) Perform a halo sign test
• C) Suction the nasal passages
• D) Apply pressure to the nose
Answer: B
Rationale: CSF leaking can be confirmed by testing for glucose and electrolyte content. The nurse should place the
fluid on white absorbent paper or linen and perform a halo sign test – a yellow ring (halo) around blood indicates
CSF.
Question 9: The nurse is providing discharge instructions to the partner of a client who sustained a mild head injury.
Which statement by the partner indicates the need for additional teaching?
• A) "I will bring my partner to the ED if they start vomiting immediately."
• B) "I will monitor for any changes in behavior."
• C) "I will wake my partner every 2 hours to check orientation."
• D) "I will avoid giving my partner aspirin for headache."
Answer: A
Rationale: Nausea and vomiting are expected symptoms after a mild head injury and usually resolve within 72
hours. Immediate vomiting does not necessarily require ED visit unless it is persistent or accompanied by other
concerning signs.
3|Page SUCCESS!!!
, Question 10: The nurse is caring for assigned clients. Which client should the nurse see FIRST?
• A) Client with a brain injury and BP change from 110/58 to 134/40 mmHg
• B) Client with a mild head injury reporting headache
• C) Client with a spinal cord injury requesting pain medication
• D) Client with burns requesting a dressing change
Answer: A
Rationale: A BP change from 110/58 to 134/40 indicates Cushing's triad – severe hypertension, widened pulse
pressure, and bradycardia – which is a late sign of increased ICP requiring immediate intervention.
Question 11: The nurse is caring for a client who is 24 hours post-op following a craniotomy. The client reports a
headache rated 8/10. What is the next action for the nurse to take?
• A) Administer pain medication as prescribed
• B) Perform a neurological assessment
• C) Notify the healthcare provider
• D) Apply a cold compress to the head
Answer: B
Rationale: The nurse should first perform a neurological assessment to determine if the headache is a sign of
increased ICP. Symptoms of increased ICP include headache, deteriorating LOC, restlessness, and irritability.
Question 12: A client with encephalitis has a change in BP from 120/78 to 130/60. What is the priority action for
the nurse?
• A) Document the finding
• B) Notify the healthcare provider
• C) Reassess in 15 minutes
• D) Administer antihypertensive medication
Answer: B
Rationale: Changes in vital signs that require immediate notification include a widened pulse pressure (130/60 =
pulse pressure 70), new bradycardia, and irregular respiratory effort – all signs of increased ICP or neurologic
deterioration.
Question 13: The nurse is caring for a client admitted with suspected bacterial meningitis. Which action should the
nurse take FIRST?
• A) Administer antibiotics
• B) Implement droplet precautions
• C) Obtain a CT scan
4|Page SUCCESS!!!
ActualQuestions And Real Reliable
Answers |Already Grade A+ Guaranteed
Pass (Charmberlain School Of Nursing )
Most Recent !!!
Question 1: The nurse is caring for a patient with a traumatic brain injury (TBI). Which finding should the nurse
recognize as the earliest sign of neurologic deterioration?
• A) Fixed pupils
• B) Decreased level of consciousness
• C) Decerebrate posturing
• D) Cushing's triad
Answer: B
Rationale: A change in level of consciousness (LOC) is the earliest indicator of neurologic deterioration and must g
Question 2: A patient has a Glasgow Coma Scale (GCS) score of 6. How should the nurse interpret this finding?
• A) Mild neurologic impairment
• B) Moderate neurologic impairment
• C) Patient is comatose
• D) Normal neurologic status
Answer: C
Rationale: A GCS score of 7 or less indicates coma and reflects severe neurologic dysfunction requiring immediate
intervention.
Question 3: The nurse observes abnormal flexion of the patient's arms, wrists, and fingers with plantar flexion of
the legs. How should this finding be documented?
1|Page SUCCESS!!!
, • A) Decerebrate posturing
• B) Flaccid paralysis
• C) Decorticate posturing
• D) Hemiparesis
Answer: C
Rationale: Decorticate (flexor) posturing is characterized by flexion of the arms, wrists, and fingers with internal
rotation and plantar flexion of the legs.
Question 4: The charge nurse is observing a newly hired nurse care for a client who sustained a closed head injury,
is receiving mechanical ventilation, and is at risk for developing ICP. Which action requires intervention by the
charge nurse?
• A) Maintaining the head midline
• B) Elevating the head of the bed to 30 degrees
• C) Raising the foot of the client's bed
• D) Minimizing environmental stimulation
Answer: C
Rationale: The head should be maintained in a midline, neutral position to prevent increased ICP. Raising the foot
of the bed is incorrect and would increase ICP.
Question 5: The newly hired nurse is caring for a client admitted 12 hours ago with a TBI and at risk for ICP.
Which action requires intervention by the nurse preceptor?
• A) Performing frequent neuro checks
• B) Clustering client care activities
• C) Keeping the room quiet and dim
• D) Maintaining HOB at 30 degrees
Answer: B
Rationale: When multiple activities are clustered in a row, the effect on ICP can be a dramatic elevation. Care
should be spaced out to avoid sudden ICP spikes.
Question 6: The nurse is assessing clients for the risk of sustaining a TBI. Which client is at greatest risk?
• A) 65-year-old female with a history of falls
• B) 20-year-old college student who plays football
• C) 45-year-old male construction worker
• D) 72-year-old male with hypertension
2|Page SUCCESS!!!
,Answer: B
Rationale: Young adults aged 15-24 are at highest risk for TBI, particularly athletes in contact sports like football.
A force produced by a blow direct to the head can contribute to brain injury.
Question 7: The nurse caring for assigned clients notes which assessment finding requires notification of the
primary healthcare provider?
• A) Headache rated 4/10
• B) Slight confusion
• C) Asymmetric pupils with no reaction to light
• D) Photophobia
Answer: C
Rationale: Pupillary changes – dilated and non-reactive pupils ("blown" pupils) or constrictive, non-reactive pupils
– indicate neurologic emergency and require immediate notification.
Question 8: The nurse is caring for a client who had a TBI with a skull fracture. The nurse notes the client has
developed rhinorrhea (nasal drip) that is positive for glucose. What action should the nurse take next?
• A) Notify the healthcare provider immediately
• B) Perform a halo sign test
• C) Suction the nasal passages
• D) Apply pressure to the nose
Answer: B
Rationale: CSF leaking can be confirmed by testing for glucose and electrolyte content. The nurse should place the
fluid on white absorbent paper or linen and perform a halo sign test – a yellow ring (halo) around blood indicates
CSF.
Question 9: The nurse is providing discharge instructions to the partner of a client who sustained a mild head injury.
Which statement by the partner indicates the need for additional teaching?
• A) "I will bring my partner to the ED if they start vomiting immediately."
• B) "I will monitor for any changes in behavior."
• C) "I will wake my partner every 2 hours to check orientation."
• D) "I will avoid giving my partner aspirin for headache."
Answer: A
Rationale: Nausea and vomiting are expected symptoms after a mild head injury and usually resolve within 72
hours. Immediate vomiting does not necessarily require ED visit unless it is persistent or accompanied by other
concerning signs.
3|Page SUCCESS!!!
, Question 10: The nurse is caring for assigned clients. Which client should the nurse see FIRST?
• A) Client with a brain injury and BP change from 110/58 to 134/40 mmHg
• B) Client with a mild head injury reporting headache
• C) Client with a spinal cord injury requesting pain medication
• D) Client with burns requesting a dressing change
Answer: A
Rationale: A BP change from 110/58 to 134/40 indicates Cushing's triad – severe hypertension, widened pulse
pressure, and bradycardia – which is a late sign of increased ICP requiring immediate intervention.
Question 11: The nurse is caring for a client who is 24 hours post-op following a craniotomy. The client reports a
headache rated 8/10. What is the next action for the nurse to take?
• A) Administer pain medication as prescribed
• B) Perform a neurological assessment
• C) Notify the healthcare provider
• D) Apply a cold compress to the head
Answer: B
Rationale: The nurse should first perform a neurological assessment to determine if the headache is a sign of
increased ICP. Symptoms of increased ICP include headache, deteriorating LOC, restlessness, and irritability.
Question 12: A client with encephalitis has a change in BP from 120/78 to 130/60. What is the priority action for
the nurse?
• A) Document the finding
• B) Notify the healthcare provider
• C) Reassess in 15 minutes
• D) Administer antihypertensive medication
Answer: B
Rationale: Changes in vital signs that require immediate notification include a widened pulse pressure (130/60 =
pulse pressure 70), new bradycardia, and irregular respiratory effort – all signs of increased ICP or neurologic
deterioration.
Question 13: The nurse is caring for a client admitted with suspected bacterial meningitis. Which action should the
nurse take FIRST?
• A) Administer antibiotics
• B) Implement droplet precautions
• C) Obtain a CT scan
4|Page SUCCESS!!!
