NUR 265 EXAM 3 VERSION 1 AND 2 NEW | ACTUAL
QUESTIONS AND ANSWERS | 2026 UPDATE | 100%
CORRECT - GALEN COLLEGE OF NURSING –
COMPREHENSIVE QUESTIONS AND ANSWERS | VERIFIED
AND WELLDETAILED ANSWERS | DETAILED
EXPLANATIONS AND RATIONALES | COMPLETE EXAM
PREPARATION STUDY GUIDE | PRACTICE QUESTIONS |
LATEST EXAM UPDATE
• CORE DOMAINS
1. Traumatic Brain Injury and Increased Intracranial Pressure (ICP)
2. Spinal Cord Injury and Neurologic Emergencies
3. Myasthenia Gravis and Neuromuscular Disorders
4. Guillain-Barré Syndrome, ALS, and Cranial Nerve Disorders
5. Meningitis and Encephalitis
6. Burn Injuries and Burn Management
7. Hypovolemic, Septic, Cardiogenic, Obstructive, and Distributive Shock
8. Critical-Care Nursing Interventions and Hemodynamic Monitoring
9. Emergency Pharmacology and Medication Safety
10. Prioritization, Clinical Judgment, and Patient Education
SECTION ONE: QUESTIONS 1–100
Question 1.
A client with a traumatic brain injury has a heart rate of 56/min, blood pressure of 166/52
mm Hg, and irregular respirations. Which finding should the nurse recognize as most
concerning?
A. Heart rate of 56/min
B. Respiratory rate of 14/min
C. Temperature of 37°C (98.6°F)
D. Oxygen saturation of 98%
,Correct Answer: A. Heart rate of 56/min
Explanation: Bradycardia occurring with widening pulse pressure and abnormal
respirations is associated with Cushing's response, which can indicate increasing
intracranial pressure and possible brain herniation.
Question 2.
Which nursing intervention is appropriate for a client at risk for increased ICP?
A. Keep the head of the bed flat
B. Elevate the head of the bed approximately 30 degrees
C. Flex the client's neck toward the chest
D. Raise the client's legs above the heart
Correct Answer: B. Elevate the head of the bed approximately 30 degrees
Explanation: Elevating the head while maintaining neutral neck alignment promotes
cerebral venous drainage and can help decrease ICP.
Question 3.
The nurse is caring for a client with a closed head injury. Which action requires intervention
by the charge nurse?
A. Maintaining the neck in neutral alignment
B. Performing frequent neurological assessments
C. Raising the foot of the bed
D. Maintaining the head of the bed at approximately 30 degrees
Correct Answer: C. Raising the foot of the bed
Explanation: Raising the foot of the bed can impair venous drainage and potentially
increase ICP. Proper positioning promotes cerebral venous return. Public NUR 265 study
material specifically identifies this intervention as inappropriate for clients at risk for ICP.
Question 4.
Which assessment finding in a client with traumatic brain injury requires immediate
notification of the provider?
A. Pupils that are equal and reactive
B. New unequal pupils with decreased reaction to light
C. Heart rate of 84/min
D. Temperature of 37°C (98.6°F)
Correct Answer: B. New unequal pupils with decreased reaction to light
Explanation: New pupillary asymmetry or sluggish/nonreactive pupils may indicate
neurological deterioration and increasing intracranial pressure.
, Question 5.
A client with a skull fracture develops clear drainage from the nose. Which test can help
determine whether the drainage may contain cerebrospinal fluid?
A. Allen test
B. Babinski test
C. Halo test
D. Romberg test
Correct Answer: C. Halo test
Explanation: A halo or ring pattern around blood on gauze may suggest the presence of
cerebrospinal fluid, which can occur with a basilar skull fracture. Public NUR 265 study
previews specifically identify glucose-positive rhinorrhea and halo testing as assessment
considerations.
Question 6.
Which medication history is particularly important when assessing a client with traumatic
brain injury?
A. Daily multivitamin use
B. Warfarin therapy
C. Calcium supplementation
D. Topical moisturizer use
Correct Answer: B. Warfarin therapy
Explanation: Warfarin increases bleeding risk. In a client with head trauma,
anticoagulation can increase the risk of intracranial hemorrhage and requires prompt
evaluation.
Question 7.
A client with a mild head injury is being discharged. Which statement indicates a need for
additional teaching?
A. “Someone should observe me after discharge.”
B. “I should return if neurological symptoms worsen.”
C. “I will seek emergency care if I develop repeated vomiting.”
D. “I can ignore new confusion because the original injury was mild.”
Correct Answer: D. “I can ignore new confusion because the original injury was mild.”
Explanation: New confusion can indicate neurological deterioration and requires prompt
evaluation regardless of the initial severity of the injury.
Question 8.
QUESTIONS AND ANSWERS | 2026 UPDATE | 100%
CORRECT - GALEN COLLEGE OF NURSING –
COMPREHENSIVE QUESTIONS AND ANSWERS | VERIFIED
AND WELLDETAILED ANSWERS | DETAILED
EXPLANATIONS AND RATIONALES | COMPLETE EXAM
PREPARATION STUDY GUIDE | PRACTICE QUESTIONS |
LATEST EXAM UPDATE
• CORE DOMAINS
1. Traumatic Brain Injury and Increased Intracranial Pressure (ICP)
2. Spinal Cord Injury and Neurologic Emergencies
3. Myasthenia Gravis and Neuromuscular Disorders
4. Guillain-Barré Syndrome, ALS, and Cranial Nerve Disorders
5. Meningitis and Encephalitis
6. Burn Injuries and Burn Management
7. Hypovolemic, Septic, Cardiogenic, Obstructive, and Distributive Shock
8. Critical-Care Nursing Interventions and Hemodynamic Monitoring
9. Emergency Pharmacology and Medication Safety
10. Prioritization, Clinical Judgment, and Patient Education
SECTION ONE: QUESTIONS 1–100
Question 1.
A client with a traumatic brain injury has a heart rate of 56/min, blood pressure of 166/52
mm Hg, and irregular respirations. Which finding should the nurse recognize as most
concerning?
A. Heart rate of 56/min
B. Respiratory rate of 14/min
C. Temperature of 37°C (98.6°F)
D. Oxygen saturation of 98%
,Correct Answer: A. Heart rate of 56/min
Explanation: Bradycardia occurring with widening pulse pressure and abnormal
respirations is associated with Cushing's response, which can indicate increasing
intracranial pressure and possible brain herniation.
Question 2.
Which nursing intervention is appropriate for a client at risk for increased ICP?
A. Keep the head of the bed flat
B. Elevate the head of the bed approximately 30 degrees
C. Flex the client's neck toward the chest
D. Raise the client's legs above the heart
Correct Answer: B. Elevate the head of the bed approximately 30 degrees
Explanation: Elevating the head while maintaining neutral neck alignment promotes
cerebral venous drainage and can help decrease ICP.
Question 3.
The nurse is caring for a client with a closed head injury. Which action requires intervention
by the charge nurse?
A. Maintaining the neck in neutral alignment
B. Performing frequent neurological assessments
C. Raising the foot of the bed
D. Maintaining the head of the bed at approximately 30 degrees
Correct Answer: C. Raising the foot of the bed
Explanation: Raising the foot of the bed can impair venous drainage and potentially
increase ICP. Proper positioning promotes cerebral venous return. Public NUR 265 study
material specifically identifies this intervention as inappropriate for clients at risk for ICP.
Question 4.
Which assessment finding in a client with traumatic brain injury requires immediate
notification of the provider?
A. Pupils that are equal and reactive
B. New unequal pupils with decreased reaction to light
C. Heart rate of 84/min
D. Temperature of 37°C (98.6°F)
Correct Answer: B. New unequal pupils with decreased reaction to light
Explanation: New pupillary asymmetry or sluggish/nonreactive pupils may indicate
neurological deterioration and increasing intracranial pressure.
, Question 5.
A client with a skull fracture develops clear drainage from the nose. Which test can help
determine whether the drainage may contain cerebrospinal fluid?
A. Allen test
B. Babinski test
C. Halo test
D. Romberg test
Correct Answer: C. Halo test
Explanation: A halo or ring pattern around blood on gauze may suggest the presence of
cerebrospinal fluid, which can occur with a basilar skull fracture. Public NUR 265 study
previews specifically identify glucose-positive rhinorrhea and halo testing as assessment
considerations.
Question 6.
Which medication history is particularly important when assessing a client with traumatic
brain injury?
A. Daily multivitamin use
B. Warfarin therapy
C. Calcium supplementation
D. Topical moisturizer use
Correct Answer: B. Warfarin therapy
Explanation: Warfarin increases bleeding risk. In a client with head trauma,
anticoagulation can increase the risk of intracranial hemorrhage and requires prompt
evaluation.
Question 7.
A client with a mild head injury is being discharged. Which statement indicates a need for
additional teaching?
A. “Someone should observe me after discharge.”
B. “I should return if neurological symptoms worsen.”
C. “I will seek emergency care if I develop repeated vomiting.”
D. “I can ignore new confusion because the original injury was mild.”
Correct Answer: D. “I can ignore new confusion because the original injury was mild.”
Explanation: New confusion can indicate neurological deterioration and requires prompt
evaluation regardless of the initial severity of the injury.
Question 8.
