NUR 265 / NUR265 EXAM 3 ADVANCED
CONCEPTS IN MEDICAL-SURGICAL
NURSING EXAM 3 | QUESTIONS AND
ANSWERS RATED A+ | 2026/2027
1. The nurse is caring for an adult client who was recently admitted with a head
injury following a motor vehicle crash. One hour ago, the client's vital signs were
T: 98.6°F; P: 110; R: 26; BP: 128/68 mm Hg. Which of the following findings is a
priority for the nurse to follow up?
A. P: 90; R: 32; BP: 130/72 mm Hg
B. P: 120; R: 26; BP: 110/70 mm Hg
C. P: 56; R: 14; BP: 166/52 mm Hg
D. P: 64; R: 30; BP: 148/78 mm Hg
Answer: C — P: 56; R: 14; BP: 166/52 mm Hg
Rationale: This finding shows Cushing's triad (bradycardia, irregular respirations, and
severe hypertension with a widened pulse pressure), which is a late sign of increased
intracranial pressure (ICP) indicating brainstem compression and impending herniation.
This is a medical emergency requiring immediate provider notification .
2. The nurse is caring for a client who sustained a closed head injury, is receiving
mechanical ventilation, and is at risk for developing increased intracranial pressure
(ICP). Which of the following actions should the nurse take when caring for this
client?
A. Perform passive range of motion (ROM) to the client's hips and knees
B. Log roll the client during turning and repositioning
C. Elevate the foot of the client's bed
D. Notify the charge nurse if the client's PaCO₂ decreases from 39 to 35 mm Hg
,Answer: B — Log roll the client during turning and repositioning
Rationale: Log rolling maintains spinal alignment and prevents sudden movements that
could increase ICP. Hip flexion (A) and neck flexion should be avoided as they increase
intra-abdominal and intrathoracic pressure. The HOB should be elevated 30-45° (not the
foot). A PaCO₂ decrease from 39 to 35 is actually beneficial as it causes vasoconstriction
and lowers ICP .
3. The newly hired nurse is caring for a client who was admitted 12 hours ago with
a traumatic brain injury (TBI), is intubated, and is at risk for developing increased
intracranial pressure (ICP). Which interventions should the nurse include in the
client's plan of care?
1. Avoid clustering client care activities
2. Maintain the head in a flexed position
3. Provide a quiet environment by limiting visitors
4. Have the client cough and deep breathe every hour
5. Hyperoxygenate the client before and after suctioning
6. Avoid maintaining hips in a flexed position
A. 1, 3, 4, 5
B. 1, 3, 5, 6
C. 1, 2, 4, 6
D. 2, 4, 6
Answer: B — 1, 3, 5, 6
Rationale: Appropriate ICP-reducing interventions include avoiding clustering care
activities (which can spike ICP), providing a quiet environment, hyperoxygenating before
and after suctioning, and avoiding hip flexion (which increases intra-abdominal
pressure). The head should be maintained in a midline neutral position (not flexed), and
coughing and deep breathing should be avoided as they increase ICP .
,4. The nurse working in the intensive care unit (ICU) is assessing a client who
sustained a basilar skull fracture 24 hours ago. It is most important to follow up
with the primary health care provider (PHCP) if the client:
A. Becomes irritable and restless
B. Has bruises under the eyes
C. Is unable to name the state capital
D. Reports having a persistent headache since admission
Answer: A — Becomes irritable and restless
Rationale: Irritability and restlessness are early signs of increasing ICP. While bruising
under the eyes (raccoon eyes) and headache are expected findings with basilar skull
fracture, a change in mental status requires immediate intervention. Inability to name
the state capital suggests confusion, but irritability/restlessness is often the earliest sign .
5. The nurse is assessing a client who has experienced a mild traumatic brain injury
(TBI). Which findings are consistent with this diagnosis?
1. Dizziness and gait problems
2. A widened pulse pressure
3. Increased sensitivity to light or noise
4. A Glasgow Coma Scale (GCS) score of 9
5. Dilated pupils that are nonreactive to light
6. Amnesia about the events around the time of injury
A. 1, 3, 6
B. 3, 5, 6
C. 2, 3, 4, 5
D. 1, 2, 4, 6
Answer: A — 1, 3, 6
Rationale: Mild TBI (concussion) presents with dizziness, gait problems, sensitivity to
light/noise, and amnesia about the injury event. A widened pulse pressure and
, nonreactive dilated pupils are signs of severe increased ICP. A GCS of 9 indicates a
moderate to severe brain injury (mild TBI is GCS 13-15) .
6. The nurse is providing discharge instructions to the parents of a 15-year-old
female who sustained a concussion while playing field hockey. Which statement by
a parent indicates a need for further teaching?
A. "We should avoid giving any acetaminophen to treat headaches."
B. "We need to bring our daughter back to the emergency department if she exhibits
blurred vision."
C. "We should provide a consistent routine at home to assist with any behavior
changes."
D. "We will not allow our daughter to engage in strenuous activity for at least 48 hours."
Answer: A — "We should avoid giving any acetaminophen to treat headaches."
Rationale: Acetaminophen is the preferred medication for headache management after
concussion. Parents should avoid aspirin and NSAIDs due to bleeding risk, but
acetaminophen is safe. Blurred vision should be reported, consistent routine helps with
behavior changes, and strenuous activity should be avoided for 48 hours .
7. The nurse is assessing clients for the risk of sustaining a traumatic brain injury
(TBI). Which client should the nurse identify as being at greatest risk?
A. 45-year-old who has epilepsy and takes phenytoin
B. 75-year-old who lives alone and has macular degeneration
C. 7-year-old who is learning how to ride a bicycle without training wheels
D. 20-year-old college student who participates on the tennis team
Answer: B — 75-year-old who lives alone and has macular degeneration
Rationale: Older adults are at highest risk for TBI due to falls, especially those with
vision impairment (macular degeneration). Falls are the leading cause of TBI in older
adults. The other clients have lower risk factors .
CONCEPTS IN MEDICAL-SURGICAL
NURSING EXAM 3 | QUESTIONS AND
ANSWERS RATED A+ | 2026/2027
1. The nurse is caring for an adult client who was recently admitted with a head
injury following a motor vehicle crash. One hour ago, the client's vital signs were
T: 98.6°F; P: 110; R: 26; BP: 128/68 mm Hg. Which of the following findings is a
priority for the nurse to follow up?
A. P: 90; R: 32; BP: 130/72 mm Hg
B. P: 120; R: 26; BP: 110/70 mm Hg
C. P: 56; R: 14; BP: 166/52 mm Hg
D. P: 64; R: 30; BP: 148/78 mm Hg
Answer: C — P: 56; R: 14; BP: 166/52 mm Hg
Rationale: This finding shows Cushing's triad (bradycardia, irregular respirations, and
severe hypertension with a widened pulse pressure), which is a late sign of increased
intracranial pressure (ICP) indicating brainstem compression and impending herniation.
This is a medical emergency requiring immediate provider notification .
2. The nurse is caring for a client who sustained a closed head injury, is receiving
mechanical ventilation, and is at risk for developing increased intracranial pressure
(ICP). Which of the following actions should the nurse take when caring for this
client?
A. Perform passive range of motion (ROM) to the client's hips and knees
B. Log roll the client during turning and repositioning
C. Elevate the foot of the client's bed
D. Notify the charge nurse if the client's PaCO₂ decreases from 39 to 35 mm Hg
,Answer: B — Log roll the client during turning and repositioning
Rationale: Log rolling maintains spinal alignment and prevents sudden movements that
could increase ICP. Hip flexion (A) and neck flexion should be avoided as they increase
intra-abdominal and intrathoracic pressure. The HOB should be elevated 30-45° (not the
foot). A PaCO₂ decrease from 39 to 35 is actually beneficial as it causes vasoconstriction
and lowers ICP .
3. The newly hired nurse is caring for a client who was admitted 12 hours ago with
a traumatic brain injury (TBI), is intubated, and is at risk for developing increased
intracranial pressure (ICP). Which interventions should the nurse include in the
client's plan of care?
1. Avoid clustering client care activities
2. Maintain the head in a flexed position
3. Provide a quiet environment by limiting visitors
4. Have the client cough and deep breathe every hour
5. Hyperoxygenate the client before and after suctioning
6. Avoid maintaining hips in a flexed position
A. 1, 3, 4, 5
B. 1, 3, 5, 6
C. 1, 2, 4, 6
D. 2, 4, 6
Answer: B — 1, 3, 5, 6
Rationale: Appropriate ICP-reducing interventions include avoiding clustering care
activities (which can spike ICP), providing a quiet environment, hyperoxygenating before
and after suctioning, and avoiding hip flexion (which increases intra-abdominal
pressure). The head should be maintained in a midline neutral position (not flexed), and
coughing and deep breathing should be avoided as they increase ICP .
,4. The nurse working in the intensive care unit (ICU) is assessing a client who
sustained a basilar skull fracture 24 hours ago. It is most important to follow up
with the primary health care provider (PHCP) if the client:
A. Becomes irritable and restless
B. Has bruises under the eyes
C. Is unable to name the state capital
D. Reports having a persistent headache since admission
Answer: A — Becomes irritable and restless
Rationale: Irritability and restlessness are early signs of increasing ICP. While bruising
under the eyes (raccoon eyes) and headache are expected findings with basilar skull
fracture, a change in mental status requires immediate intervention. Inability to name
the state capital suggests confusion, but irritability/restlessness is often the earliest sign .
5. The nurse is assessing a client who has experienced a mild traumatic brain injury
(TBI). Which findings are consistent with this diagnosis?
1. Dizziness and gait problems
2. A widened pulse pressure
3. Increased sensitivity to light or noise
4. A Glasgow Coma Scale (GCS) score of 9
5. Dilated pupils that are nonreactive to light
6. Amnesia about the events around the time of injury
A. 1, 3, 6
B. 3, 5, 6
C. 2, 3, 4, 5
D. 1, 2, 4, 6
Answer: A — 1, 3, 6
Rationale: Mild TBI (concussion) presents with dizziness, gait problems, sensitivity to
light/noise, and amnesia about the injury event. A widened pulse pressure and
, nonreactive dilated pupils are signs of severe increased ICP. A GCS of 9 indicates a
moderate to severe brain injury (mild TBI is GCS 13-15) .
6. The nurse is providing discharge instructions to the parents of a 15-year-old
female who sustained a concussion while playing field hockey. Which statement by
a parent indicates a need for further teaching?
A. "We should avoid giving any acetaminophen to treat headaches."
B. "We need to bring our daughter back to the emergency department if she exhibits
blurred vision."
C. "We should provide a consistent routine at home to assist with any behavior
changes."
D. "We will not allow our daughter to engage in strenuous activity for at least 48 hours."
Answer: A — "We should avoid giving any acetaminophen to treat headaches."
Rationale: Acetaminophen is the preferred medication for headache management after
concussion. Parents should avoid aspirin and NSAIDs due to bleeding risk, but
acetaminophen is safe. Blurred vision should be reported, consistent routine helps with
behavior changes, and strenuous activity should be avoided for 48 hours .
7. The nurse is assessing clients for the risk of sustaining a traumatic brain injury
(TBI). Which client should the nurse identify as being at greatest risk?
A. 45-year-old who has epilepsy and takes phenytoin
B. 75-year-old who lives alone and has macular degeneration
C. 7-year-old who is learning how to ride a bicycle without training wheels
D. 20-year-old college student who participates on the tennis team
Answer: B — 75-year-old who lives alone and has macular degeneration
Rationale: Older adults are at highest risk for TBI due to falls, especially those with
vision impairment (macular degeneration). Falls are the leading cause of TBI in older
adults. The other clients have lower risk factors .
