,NR 325 Exam 2 Adult Health II | Questions And Answers | 2026/2027
CHAMBERLAIN
1.** A nurse is assessing a client with a suspected brain injury. Which finding
indicates increased intracranial pressure (ICP)?
A) Blood pressure 100/60 mmHg, pulse 100/min
B) Blood pressure 150/90 mmHg, pulse 60/min
C) Pupils equal and reactive
D) Glasgow Coma Scale 15
**Correct Answer:** B) Blood pressure 150/90 mmHg, pulse 60/min
**Rationale:** Cushing's triad—hypertension, bradycardia, and irregular
respirations—indicates increased ICP. Normal vital signs and GCS 15 do not
indicate increased ICP. This is a medical emergency requiring immediate
intervention.
**2.** A nurse is caring for a client with increased ICP. Which position should
the nurse place the client in?
A) Supine with the head of the bed flat
B) High-Fowler's position
C) The head of the bed elevated 30 degrees with the head in a midline
position
D) Trendelenburg position
**Correct Answer:** C) The head of the bed elevated 30 degrees with the
head in a midline position
,**Rationale:** Elevating the head of the bed to 30 degrees promotes venous
drainage and reduces ICP. The head should be kept in a midline position to
avoid jugular vein compression. Supine (A) and Trendelenburg (D) positions
increase ICP.
**3.** A client with a traumatic brain injury has a Glasgow Coma Scale (GCS)
score of 8. Which action should the nurse take?
A) Document the score and continue monitoring
B) Notify the healthcare provider immediately
C) Prepare for intubation
D) Administer sedation
**Correct Answer:** C) Prepare for intubation
**Rationale:** A GCS score of 8 or less indicates severe brain injury and the
need for airway protection. Intubation is often required to maintain airway
patency and prevent aspiration. Notifying the provider (B) is appropriate but
preparing for intubation is the priority.
**4.** A nurse is assessing a client's pupils. Which finding indicates increased
ICP?
A) Pupils are equal and reactive
B) Pupils are dilated and fixed
C) Pupils are constricted and reactive
D) Pupils are unequal with a sluggish response
**Correct Answer:** D) Pupils are unequal with a sluggish response
, **Rationale:** Unequal pupils (anisocoria) with a sluggish or absent response
may indicate increased ICP and possible herniation. Dilated and fixed pupils
(B) are a late sign of severe increased ICP. Equal and reactive pupils (A) are
normal.
**5.** A nurse is caring for a client with increased ICP. Which of the following
interventions should the nurse implement? (Select all that apply.)
A) Maintain the head of the bed elevated 30 degrees
B) Cluster nursing activities to minimize stimulation
C) Administer stool softeners to prevent straining
D) Encourage the client to cough and deep breathe
E) Maintain the head in a midline position
**Correct Answers:** A, B, C, E
**Rationale:** Interventions to reduce ICP include elevating the head of the
bed (A), clustering activities to minimize stimulation (B), preventing straining
with stool softeners (C), and maintaining the head in a midline position (E).
Coughing and deep breathing (D) increase ICP and should be avoided.
**6.** A client with increased ICP is prescribed mannitol. What is the purpose
of this medication?
A) To decrease cerebral edema
B) To increase blood pressure
C) To promote diuresis
D) Both A and C
CHAMBERLAIN
1.** A nurse is assessing a client with a suspected brain injury. Which finding
indicates increased intracranial pressure (ICP)?
A) Blood pressure 100/60 mmHg, pulse 100/min
B) Blood pressure 150/90 mmHg, pulse 60/min
C) Pupils equal and reactive
D) Glasgow Coma Scale 15
**Correct Answer:** B) Blood pressure 150/90 mmHg, pulse 60/min
**Rationale:** Cushing's triad—hypertension, bradycardia, and irregular
respirations—indicates increased ICP. Normal vital signs and GCS 15 do not
indicate increased ICP. This is a medical emergency requiring immediate
intervention.
**2.** A nurse is caring for a client with increased ICP. Which position should
the nurse place the client in?
A) Supine with the head of the bed flat
B) High-Fowler's position
C) The head of the bed elevated 30 degrees with the head in a midline
position
D) Trendelenburg position
**Correct Answer:** C) The head of the bed elevated 30 degrees with the
head in a midline position
,**Rationale:** Elevating the head of the bed to 30 degrees promotes venous
drainage and reduces ICP. The head should be kept in a midline position to
avoid jugular vein compression. Supine (A) and Trendelenburg (D) positions
increase ICP.
**3.** A client with a traumatic brain injury has a Glasgow Coma Scale (GCS)
score of 8. Which action should the nurse take?
A) Document the score and continue monitoring
B) Notify the healthcare provider immediately
C) Prepare for intubation
D) Administer sedation
**Correct Answer:** C) Prepare for intubation
**Rationale:** A GCS score of 8 or less indicates severe brain injury and the
need for airway protection. Intubation is often required to maintain airway
patency and prevent aspiration. Notifying the provider (B) is appropriate but
preparing for intubation is the priority.
**4.** A nurse is assessing a client's pupils. Which finding indicates increased
ICP?
A) Pupils are equal and reactive
B) Pupils are dilated and fixed
C) Pupils are constricted and reactive
D) Pupils are unequal with a sluggish response
**Correct Answer:** D) Pupils are unequal with a sluggish response
, **Rationale:** Unequal pupils (anisocoria) with a sluggish or absent response
may indicate increased ICP and possible herniation. Dilated and fixed pupils
(B) are a late sign of severe increased ICP. Equal and reactive pupils (A) are
normal.
**5.** A nurse is caring for a client with increased ICP. Which of the following
interventions should the nurse implement? (Select all that apply.)
A) Maintain the head of the bed elevated 30 degrees
B) Cluster nursing activities to minimize stimulation
C) Administer stool softeners to prevent straining
D) Encourage the client to cough and deep breathe
E) Maintain the head in a midline position
**Correct Answers:** A, B, C, E
**Rationale:** Interventions to reduce ICP include elevating the head of the
bed (A), clustering activities to minimize stimulation (B), preventing straining
with stool softeners (C), and maintaining the head in a midline position (E).
Coughing and deep breathing (D) increase ICP and should be avoided.
**6.** A client with increased ICP is prescribed mannitol. What is the purpose
of this medication?
A) To decrease cerebral edema
B) To increase blood pressure
C) To promote diuresis
D) Both A and C
