,NU 189 EXAM 1 Medical-Surgical Nursing II Questions And Answers
2026/2027 Galen College
Q1. A client exhibits adduction of the arms with flexion of the
elbows and wrists. Which type of posturing should the nurse
document?
A) Decerebrate
B) Decorticate
C) Flaccid
D) Opisthotonos
Correct Answer: B) Decorticate
Rationale: Decorticate posturing is characterized by flexion of the upper
extremities and extension of the lower extremities and indicates significant
neurologic dysfunction.
Q2. A client with a traumatic brain injury develops extension and
internal rotation of the arms. Which finding does this represent?
A) Decorticate posturing
B) Flaccid paralysis
C) Decerebrate posturing
D) Hemiparesis
Correct Answer: C) Decerebrate posturing
Rationale: Decerebrate posturing involves extension and abnormal rotation
of the upper extremities and indicates severe brain dysfunction.
Q3. Which finding is often the earliest indication of increased
intracranial pressure?
A) Decreased level of consciousness
B) Bradycardia
C) Widened pulse pressure
D) Irregular respirations
Correct Answer: A) Decreased level of consciousness
Rationale: A change in level of consciousness is often an early and sensitive
indicator of increasing intracranial pressure.
Q4. Which combination represents Cushing triad?
, A) Tachycardia, hypotension, shallow respirations
B) Hypertension, bradycardia, irregular respirations
C) Hypotension, tachypnea, fever
D) Bradycardia, hypothermia, tachypnea
Correct Answer: B) Hypertension, bradycardia, irregular respirations
Rationale: Cushing triad is a late sign of increased intracranial pressure and
consists of hypertension with widened pulse pressure, bradycardia, and
irregular respirations.
Q5. Which assessment finding suggests worsening neurologic status
in a client with a head injury?
A) Alertness improving
B) Equal reactive pupils
C) Increasing lethargy
D) Normal speech
Correct Answer: C) Increasing lethargy
Rationale: Increasing lethargy or decreased responsiveness can indicate
worsening cerebral function and rising intracranial pressure.
Q6. A client with a head injury develops one pupil that is larger than
the other. What should the nurse do?
A) Document it as an expected finding
B) Reassess at the end of the shift
C) Report the change promptly
D) Encourage oral fluids
Correct Answer: C) Report the change promptly
Rationale: A new unequal pupil size may indicate neurologic deterioration or
intracranial compression and requires prompt evaluation.
**Q7. Which intervention helps reduce intracranial pressure?
A) Keep the head and neck in neutral alignment
B) Encourage frequent hip flexion
C) Place the client flat
D) Encourage vigorous coughing
Correct Answer: A) Keep the head and neck in neutral alignment
2026/2027 Galen College
Q1. A client exhibits adduction of the arms with flexion of the
elbows and wrists. Which type of posturing should the nurse
document?
A) Decerebrate
B) Decorticate
C) Flaccid
D) Opisthotonos
Correct Answer: B) Decorticate
Rationale: Decorticate posturing is characterized by flexion of the upper
extremities and extension of the lower extremities and indicates significant
neurologic dysfunction.
Q2. A client with a traumatic brain injury develops extension and
internal rotation of the arms. Which finding does this represent?
A) Decorticate posturing
B) Flaccid paralysis
C) Decerebrate posturing
D) Hemiparesis
Correct Answer: C) Decerebrate posturing
Rationale: Decerebrate posturing involves extension and abnormal rotation
of the upper extremities and indicates severe brain dysfunction.
Q3. Which finding is often the earliest indication of increased
intracranial pressure?
A) Decreased level of consciousness
B) Bradycardia
C) Widened pulse pressure
D) Irregular respirations
Correct Answer: A) Decreased level of consciousness
Rationale: A change in level of consciousness is often an early and sensitive
indicator of increasing intracranial pressure.
Q4. Which combination represents Cushing triad?
, A) Tachycardia, hypotension, shallow respirations
B) Hypertension, bradycardia, irregular respirations
C) Hypotension, tachypnea, fever
D) Bradycardia, hypothermia, tachypnea
Correct Answer: B) Hypertension, bradycardia, irregular respirations
Rationale: Cushing triad is a late sign of increased intracranial pressure and
consists of hypertension with widened pulse pressure, bradycardia, and
irregular respirations.
Q5. Which assessment finding suggests worsening neurologic status
in a client with a head injury?
A) Alertness improving
B) Equal reactive pupils
C) Increasing lethargy
D) Normal speech
Correct Answer: C) Increasing lethargy
Rationale: Increasing lethargy or decreased responsiveness can indicate
worsening cerebral function and rising intracranial pressure.
Q6. A client with a head injury develops one pupil that is larger than
the other. What should the nurse do?
A) Document it as an expected finding
B) Reassess at the end of the shift
C) Report the change promptly
D) Encourage oral fluids
Correct Answer: C) Report the change promptly
Rationale: A new unequal pupil size may indicate neurologic deterioration or
intracranial compression and requires prompt evaluation.
**Q7. Which intervention helps reduce intracranial pressure?
A) Keep the head and neck in neutral alignment
B) Encourage frequent hip flexion
C) Place the client flat
D) Encourage vigorous coughing
Correct Answer: A) Keep the head and neck in neutral alignment
