NUR 265
NUR 265 Exam 3 with Questions & Correct
Answers and Full Deep Expert Rationales | Latest
(2026/2027) Updated Version – Galen College of
Nursing.
THIS DOCUMENT CONTAINS:
❖NUR 265 Exam 3
❖Exam 3 with Questions & Correct Answers
❖Full Deep Expert Rationales
❖Galen College of Nursing.
❖Latest (2026/2027) Updated Version
❖100% Guaranteed Pass
,NUR265 Exam 3
1. Head Injury: Priority Assessment
A nurse is caring for an adult client admitted with a head injury following a motor
vehicle crash. One hour ago, the client's vital signs were: temperature 98.6°F, pulse
110/min, respirations 26/min, and blood pressure 128/68 mm Hg.
Which finding is the priority for the nurse to follow up?
A. Pulse 90/min, respirations 32/min, blood pressure 130/72 mm Hg
B. Pulse 120/min, respirations 26/min, blood pressure 110/70 mm Hg
C. Pulse 56/min, respirations 14/min, blood pressure 166/52 mm Hg
D. Pulse 64/min, respirations 30/min, blood pressure 148/78 mm Hg
Correct Answer: C
Expert Rationale: Bradycardia, widened pulse pressure, and hypertension are
classic manifestations of increasing intracranial pressure and possible Cushing's
response. A blood pressure of 166/52 mm Hg produces a widened pulse pressure,
while the pulse of 56/min indicates bradycardia. These findings may signal
brainstem compression and require immediate intervention.
2. Preventing Increased Intracranial Pressure
A nurse is caring for a client with a closed head injury who is receiving mechanical
ventilation and is at risk for increased intracranial pressure (ICP). Which action
should the nurse take?
A. Perform passive range-of-motion exercises 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.
Correct Answer: B
Expert Rationale: The nurse should maintain proper body alignment and
minimize unnecessary movement in clients at risk for increased ICP. Log-rolling
helps prevent twisting of the body and excessive stimulation. Hip flexion can
increase intra-abdominal and intrathoracic pressure, impairing cerebral venous
drainage. Elevating the foot of the bed can also increase ICP. Mild reduction in
PaCO₂ from 39 to 35 mm Hg is not the priority finding listed.
3. Traumatic Brain Injury: Nursing Interventions
A newly hired nurse is caring for a client admitted 12 hours ago with a traumatic
brain injury. The client is intubated and at risk for increased ICP.
Which interventions should the nurse include in the client's plan of care? Select all
that apply.
1. Avoid clustering client care activities.
2. Maintain the client's 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 the client's hips in a flexed position.
A. 1, 3, 5, and 6
B. 1, 2, 4, and 5
C. 2, 3, 4, and 6
, D. 3, 4, 5, and 6
Correct Answer: A
Expert Rationale: Nursing care should minimize stimulation and prevent factors
that increase ICP. Care activities should be spaced out rather than clustered. A
quiet environment reduces stimulation. Hyperoxygenation before and after
suctioning helps prevent hypoxemia, which can worsen cerebral injury. Hip flexion
should be avoided because it can impede venous drainage from the brain. The head
should remain in neutral alignment, and coughing can transiently increase ICP.
4. Basilar Skull Fracture
A nurse in the ICU is assessing a client who sustained a basilar skull fracture 24
hours ago. Which finding is most important to report to the primary health care
provider?
A. The client becomes irritable and restless.
B. The client has bruising beneath the eyes.
C. The client is unable to name the state capital.
D. The client reports a persistent headache since admission.
Correct Answer: A
Expert Rationale: Increasing restlessness and irritability can indicate neurological
deterioration and increasing ICP. These changes in level of consciousness may
occur early and require immediate evaluation. Periorbital ecchymosis can occur
with a basilar skull fracture. Difficulty with a specific cognitive task and headache
require assessment, but an acute change in behavior or consciousness is the greater
priority.
NUR 265 Exam 3 with Questions & Correct
Answers and Full Deep Expert Rationales | Latest
(2026/2027) Updated Version – Galen College of
Nursing.
THIS DOCUMENT CONTAINS:
❖NUR 265 Exam 3
❖Exam 3 with Questions & Correct Answers
❖Full Deep Expert Rationales
❖Galen College of Nursing.
❖Latest (2026/2027) Updated Version
❖100% Guaranteed Pass
,NUR265 Exam 3
1. Head Injury: Priority Assessment
A nurse is caring for an adult client admitted with a head injury following a motor
vehicle crash. One hour ago, the client's vital signs were: temperature 98.6°F, pulse
110/min, respirations 26/min, and blood pressure 128/68 mm Hg.
Which finding is the priority for the nurse to follow up?
A. Pulse 90/min, respirations 32/min, blood pressure 130/72 mm Hg
B. Pulse 120/min, respirations 26/min, blood pressure 110/70 mm Hg
C. Pulse 56/min, respirations 14/min, blood pressure 166/52 mm Hg
D. Pulse 64/min, respirations 30/min, blood pressure 148/78 mm Hg
Correct Answer: C
Expert Rationale: Bradycardia, widened pulse pressure, and hypertension are
classic manifestations of increasing intracranial pressure and possible Cushing's
response. A blood pressure of 166/52 mm Hg produces a widened pulse pressure,
while the pulse of 56/min indicates bradycardia. These findings may signal
brainstem compression and require immediate intervention.
2. Preventing Increased Intracranial Pressure
A nurse is caring for a client with a closed head injury who is receiving mechanical
ventilation and is at risk for increased intracranial pressure (ICP). Which action
should the nurse take?
A. Perform passive range-of-motion exercises 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.
Correct Answer: B
Expert Rationale: The nurse should maintain proper body alignment and
minimize unnecessary movement in clients at risk for increased ICP. Log-rolling
helps prevent twisting of the body and excessive stimulation. Hip flexion can
increase intra-abdominal and intrathoracic pressure, impairing cerebral venous
drainage. Elevating the foot of the bed can also increase ICP. Mild reduction in
PaCO₂ from 39 to 35 mm Hg is not the priority finding listed.
3. Traumatic Brain Injury: Nursing Interventions
A newly hired nurse is caring for a client admitted 12 hours ago with a traumatic
brain injury. The client is intubated and at risk for increased ICP.
Which interventions should the nurse include in the client's plan of care? Select all
that apply.
1. Avoid clustering client care activities.
2. Maintain the client's 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 the client's hips in a flexed position.
A. 1, 3, 5, and 6
B. 1, 2, 4, and 5
C. 2, 3, 4, and 6
, D. 3, 4, 5, and 6
Correct Answer: A
Expert Rationale: Nursing care should minimize stimulation and prevent factors
that increase ICP. Care activities should be spaced out rather than clustered. A
quiet environment reduces stimulation. Hyperoxygenation before and after
suctioning helps prevent hypoxemia, which can worsen cerebral injury. Hip flexion
should be avoided because it can impede venous drainage from the brain. The head
should remain in neutral alignment, and coughing can transiently increase ICP.
4. Basilar Skull Fracture
A nurse in the ICU is assessing a client who sustained a basilar skull fracture 24
hours ago. Which finding is most important to report to the primary health care
provider?
A. The client becomes irritable and restless.
B. The client has bruising beneath the eyes.
C. The client is unable to name the state capital.
D. The client reports a persistent headache since admission.
Correct Answer: A
Expert Rationale: Increasing restlessness and irritability can indicate neurological
deterioration and increasing ICP. These changes in level of consciousness may
occur early and require immediate evaluation. Periorbital ecchymosis can occur
with a basilar skull fracture. Difficulty with a specific cognitive task and headache
require assessment, but an acute change in behavior or consciousness is the greater
priority.
