NUR 265/NUR265: Exam 3
Advanced Concepts in Medical-Surgical Nursing
2026-2028 Testing Cycle | Complete Guide
50 Questions With Answers & Expert Rationales.
Guaranteed Pass | Graded A+ | Galen
Q1: A patient with a traumatic brain injury is being monitored in the neuro ICU. The nurse notes
a widening pulse pressure, bradycardia, and irregular respiratory pattern. Which
pathophysiological principle explains these findings?
A. The Monroe-Kellie hypothesis and Cushing's reflex response to critically elevated ICP
B. Compensatory sympathetic discharge causing tachycardia and hypertension
C. Cerebral vasodilation due to hypocapnia and alkalosis
D. Increased cerebral spinal fluid production exceeding absorption capacity
Correct Answer: A
Rationale: Correct because the triad of bradycardia, severe bradypnea, and widening pulse
pressure constitutes Cushing's triad, representing the brainstem's decompensatory response to
critically elevated intracranial pressure as described by the Monroe-Kellie hypothesis. This
occurs when compensatory mechanisms for intracranial volume are exhausted and brainstem
compression triggers parasympathetic-mediated bradycardia. The nurse must recognize this as a
neurosurgical emergency requiring immediate intervention to prevent herniation.
Q2: A patient with a complete spinal cord injury at T4 is admitted to the ICU. The nurse
observes a blood pressure of 82/50 mmHg, heart rate of 54 bpm, and warm, flushed skin. Which
statement best describes the pathophysiology of this presentation?
A. Massive vasoconstriction and catecholamine surge causing tachycardia
B. Hypovolemia from third-spacing with compensatory tachycardia
C. Cardiogenic pump failure with pulmonary edema
D. Loss of sympathetic tone below the injury level causing vasodilation and unopposed vagal
activity
Correct Answer: D
Rationale: Correct because neurogenic shock results from the disruption of sympathetic outflow
below the level of spinal cord injury, leading to massive vasodilation, hypotension, and
,bradycardia due to unopposed parasympathetic vagal tone. Unlike all other shock states that
present with compensatory tachycardia, neurogenic shock is uniquely characterized by
bradycardia with hypotension. The warm, dry skin reflects peripheral vasodilation rather than the
cool, clammy skin of hypovolemic or cardiogenic shock.
Q3: A patient with an acute ischemic stroke is receiving tissue plasminogen activator (tPA).
Which blood pressure parameter must the nurse maintain during the infusion?
A. Systolic blood pressure ≤220 mmHg and diastolic ≤120 mmHg
B. Systolic blood pressure ≤160 mmHg and diastolic ≤90 mmHg
C. Systolic blood pressure ≤180 mmHg and diastolic ≤105 mmHg
D. Systolic blood pressure ≤140 mmHg and diastolic ≤90 mmHg
Correct Answer: C
Rationale: Correct because during tPA administration for acute ischemic stroke, blood pressure
must be strictly maintained at systolic ≤180 mmHg and diastolic ≤105 mmHg to minimize the
risk of hemorrhagic conversion of the infarct. Excessive blood pressure lowering is also avoided
to prevent compromising cerebral perfusion in the ischemic penumbra. The nurse must
administer antihypertensives per protocol and monitor blood pressure at frequent intervals
throughout the infusion.
Q4: A patient with a severe traumatic brain injury is at risk for increased intracranial pressure.
Which nursing interventions are appropriate? Select all that apply.
A. Cluster all care activities to minimize patient stimulation
B. Maintain head of bed at 30 degrees with neutral neck alignment
C. Hyperventilate the patient to a PaCO₂ of 20–25 mmHg continuously
D. Administer mannitol as prescribed for acute ICP spikes
E. Pre-oxygenate with 100% oxygen before suctioning and limit suctioning to less than 10
seconds
Correct Answer(s): B, E
Rationale: Correct because maintaining the head of bed at 30 degrees with neutral neck
alignment promotes cerebral venous drainage without compressing the jugular veins, and pre-
oxygenation with brief suctioning prevents hypoxia-induced cerebral vasodilation that spikes
ICP. Clustering care is contraindicated because cumulative stimuli cause sustained ICP
elevations, and prolonged hyperventilation to 20–25 mmHg causes dangerous cerebral
vasoconstriction and ischemia. Mannitol is appropriate for acute spikes but requires monitoring
of fluid and electrolyte balance.
, Q5: A patient with full-thickness burns to the anterior trunk and both arms is in the emergent
phase of burn injury. Which finding requires immediate intervention by the nurse?
A. Urine output of 40 mL/hr
B. Stridor and hoarseness with facial burns
C. White blood cell count of 12,000/mm³
D. Heart rate of 110 bpm
Correct Answer: B
Rationale: Correct because stridor and hoarseness in a patient with facial burns indicate upper
airway edema from inhalation injury, which can rapidly progress to complete airway obstruction
requiring immediate intubation. Airway protection is the highest priority in the emergent phase
of burn care. A urine output of 40 mL/hr is acceptable, mild leukocytosis is expected post-injury,
and tachycardia is a normal compensatory response to fluid shifts and pain.
Q6: A patient is brought to the emergency department following a motor vehicle accident. The
patient takes daily warfarin and has a suspected closed-head injury. Which is the priority nursing
action?
A. Notify the provider immediately and prepare for anticoagulant reversal agents
B. Administer tissue plasminogen activator prophylactically
C. Place the patient in Trendelenburg position to increase cerebral perfusion
D. Administer aspirin 325 mg to prevent secondary stroke
Correct Answer: A
Rationale: Correct because anticoagulation with warfarin drastically increases the risk of lethal
intracranial hemorrhage following traumatic brain injury, necessitating immediate provider
notification and preparation for reversal with vitamin K and 4-factor prothrombin complex
concentrate. TPA and aspirin are absolutely contraindicated in acute trauma as they would
worsen bleeding. Trendelenburg position increases intracranial pressure and is contraindicated in
head injury.
Q7: A patient with a Glasgow Coma Scale score of 7 arrives in the emergency department. The
patient opens eyes to pain, makes incomprehensible sounds, and withdraws from painful stimuli.
Which intervention is indicated?
A. Insert a nasogastric tube for enteral feeding
B. Administer oral antiepileptic medications
C. Encourage the patient to use an incentive spirometer
D. Prepare for intubation and mechanical ventilation
Advanced Concepts in Medical-Surgical Nursing
2026-2028 Testing Cycle | Complete Guide
50 Questions With Answers & Expert Rationales.
Guaranteed Pass | Graded A+ | Galen
Q1: A patient with a traumatic brain injury is being monitored in the neuro ICU. The nurse notes
a widening pulse pressure, bradycardia, and irregular respiratory pattern. Which
pathophysiological principle explains these findings?
A. The Monroe-Kellie hypothesis and Cushing's reflex response to critically elevated ICP
B. Compensatory sympathetic discharge causing tachycardia and hypertension
C. Cerebral vasodilation due to hypocapnia and alkalosis
D. Increased cerebral spinal fluid production exceeding absorption capacity
Correct Answer: A
Rationale: Correct because the triad of bradycardia, severe bradypnea, and widening pulse
pressure constitutes Cushing's triad, representing the brainstem's decompensatory response to
critically elevated intracranial pressure as described by the Monroe-Kellie hypothesis. This
occurs when compensatory mechanisms for intracranial volume are exhausted and brainstem
compression triggers parasympathetic-mediated bradycardia. The nurse must recognize this as a
neurosurgical emergency requiring immediate intervention to prevent herniation.
Q2: A patient with a complete spinal cord injury at T4 is admitted to the ICU. The nurse
observes a blood pressure of 82/50 mmHg, heart rate of 54 bpm, and warm, flushed skin. Which
statement best describes the pathophysiology of this presentation?
A. Massive vasoconstriction and catecholamine surge causing tachycardia
B. Hypovolemia from third-spacing with compensatory tachycardia
C. Cardiogenic pump failure with pulmonary edema
D. Loss of sympathetic tone below the injury level causing vasodilation and unopposed vagal
activity
Correct Answer: D
Rationale: Correct because neurogenic shock results from the disruption of sympathetic outflow
below the level of spinal cord injury, leading to massive vasodilation, hypotension, and
,bradycardia due to unopposed parasympathetic vagal tone. Unlike all other shock states that
present with compensatory tachycardia, neurogenic shock is uniquely characterized by
bradycardia with hypotension. The warm, dry skin reflects peripheral vasodilation rather than the
cool, clammy skin of hypovolemic or cardiogenic shock.
Q3: A patient with an acute ischemic stroke is receiving tissue plasminogen activator (tPA).
Which blood pressure parameter must the nurse maintain during the infusion?
A. Systolic blood pressure ≤220 mmHg and diastolic ≤120 mmHg
B. Systolic blood pressure ≤160 mmHg and diastolic ≤90 mmHg
C. Systolic blood pressure ≤180 mmHg and diastolic ≤105 mmHg
D. Systolic blood pressure ≤140 mmHg and diastolic ≤90 mmHg
Correct Answer: C
Rationale: Correct because during tPA administration for acute ischemic stroke, blood pressure
must be strictly maintained at systolic ≤180 mmHg and diastolic ≤105 mmHg to minimize the
risk of hemorrhagic conversion of the infarct. Excessive blood pressure lowering is also avoided
to prevent compromising cerebral perfusion in the ischemic penumbra. The nurse must
administer antihypertensives per protocol and monitor blood pressure at frequent intervals
throughout the infusion.
Q4: A patient with a severe traumatic brain injury is at risk for increased intracranial pressure.
Which nursing interventions are appropriate? Select all that apply.
A. Cluster all care activities to minimize patient stimulation
B. Maintain head of bed at 30 degrees with neutral neck alignment
C. Hyperventilate the patient to a PaCO₂ of 20–25 mmHg continuously
D. Administer mannitol as prescribed for acute ICP spikes
E. Pre-oxygenate with 100% oxygen before suctioning and limit suctioning to less than 10
seconds
Correct Answer(s): B, E
Rationale: Correct because maintaining the head of bed at 30 degrees with neutral neck
alignment promotes cerebral venous drainage without compressing the jugular veins, and pre-
oxygenation with brief suctioning prevents hypoxia-induced cerebral vasodilation that spikes
ICP. Clustering care is contraindicated because cumulative stimuli cause sustained ICP
elevations, and prolonged hyperventilation to 20–25 mmHg causes dangerous cerebral
vasoconstriction and ischemia. Mannitol is appropriate for acute spikes but requires monitoring
of fluid and electrolyte balance.
, Q5: A patient with full-thickness burns to the anterior trunk and both arms is in the emergent
phase of burn injury. Which finding requires immediate intervention by the nurse?
A. Urine output of 40 mL/hr
B. Stridor and hoarseness with facial burns
C. White blood cell count of 12,000/mm³
D. Heart rate of 110 bpm
Correct Answer: B
Rationale: Correct because stridor and hoarseness in a patient with facial burns indicate upper
airway edema from inhalation injury, which can rapidly progress to complete airway obstruction
requiring immediate intubation. Airway protection is the highest priority in the emergent phase
of burn care. A urine output of 40 mL/hr is acceptable, mild leukocytosis is expected post-injury,
and tachycardia is a normal compensatory response to fluid shifts and pain.
Q6: A patient is brought to the emergency department following a motor vehicle accident. The
patient takes daily warfarin and has a suspected closed-head injury. Which is the priority nursing
action?
A. Notify the provider immediately and prepare for anticoagulant reversal agents
B. Administer tissue plasminogen activator prophylactically
C. Place the patient in Trendelenburg position to increase cerebral perfusion
D. Administer aspirin 325 mg to prevent secondary stroke
Correct Answer: A
Rationale: Correct because anticoagulation with warfarin drastically increases the risk of lethal
intracranial hemorrhage following traumatic brain injury, necessitating immediate provider
notification and preparation for reversal with vitamin K and 4-factor prothrombin complex
concentrate. TPA and aspirin are absolutely contraindicated in acute trauma as they would
worsen bleeding. Trendelenburg position increases intracranial pressure and is contraindicated in
head injury.
Q7: A patient with a Glasgow Coma Scale score of 7 arrives in the emergency department. The
patient opens eyes to pain, makes incomprehensible sounds, and withdraws from painful stimuli.
Which intervention is indicated?
A. Insert a nasogastric tube for enteral feeding
B. Administer oral antiepileptic medications
C. Encourage the patient to use an incentive spirometer
D. Prepare for intubation and mechanical ventilation
