NU 185
Medical-Surgical Nursing II - Exam 4 Study Guide
Exam 4 • Practice Questions & Rationales
UPDATE
Actual Questions & Verified Answers
with Detailed Clinical Rationales
Practice Questions with Rationales
Galen College of Nursing
NU 185
✓ 100% Verified Answers
✓ Complete Rationales Included
Exam (elaborations)
Instant PDF Download • Ready for Study
,NU 185 Medical-Surgical Nursing II - Exam 4 Study Guide 2026/2027 UPDATE – Galen
1. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg.
Which of the following assessment findings would indicate the development of Cushing’s
Triad?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, widening pulse pressure, and irregular respirations
C. Narrowed pulse pressure, tachycardia, and bradypnea
D. Hypotension, bradycardia, and Cheyne-Stokes respirations
Answer: B
Rationale: Cushing’s Triad is a late sign of increased ICP and consists of bradycardia,
hypertension with a widening pulse pressure, and irregular (Cheyne-Stokes) respirations.
2. The nurse is administering Mannitol to a patient with increased ICP. Which monitoring
parameter is the priority to prevent a common complication of this medication?
A. Serum glucose levels
B. Deep tendon reflexes
C. Breath sounds for crackles
D. Peripheral pulses
, Answer: C
Rationale: Mannitol is an osmotic diuretic that pulls fluid into the vascular space. A major
complication is fluid volume overload and pulmonary edema; therefore, monitoring breath
sounds is critical.
3. A patient with a T4 spinal cord injury (SCI) reports a sudden, throbbing headache and has a
blood pressure of 190/100 mmHg. What is the nurse’s first action?
A. Place the patient in a high-Fowler’s position
B. Administer PRN Hydralazine intravenously
C. Check the patient’s urinary catheter for kinks
D. Notify the healthcare provider immediately
Answer: A
Rationale: The symptoms suggest Autonomic Dysreflexia. The priority action is to sit the
patient upright (high-Fowler’s) to lower blood pressure via orthostatic effect before
addressing the cause.
4. Which Glasgow Coma Scale (GCS) score would require the nurse to prepare for immediate
endotracheal intubation?
A. 12
B. 10
C. 8
Medical-Surgical Nursing II - Exam 4 Study Guide
Exam 4 • Practice Questions & Rationales
UPDATE
Actual Questions & Verified Answers
with Detailed Clinical Rationales
Practice Questions with Rationales
Galen College of Nursing
NU 185
✓ 100% Verified Answers
✓ Complete Rationales Included
Exam (elaborations)
Instant PDF Download • Ready for Study
,NU 185 Medical-Surgical Nursing II - Exam 4 Study Guide 2026/2027 UPDATE – Galen
1. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg.
Which of the following assessment findings would indicate the development of Cushing’s
Triad?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, widening pulse pressure, and irregular respirations
C. Narrowed pulse pressure, tachycardia, and bradypnea
D. Hypotension, bradycardia, and Cheyne-Stokes respirations
Answer: B
Rationale: Cushing’s Triad is a late sign of increased ICP and consists of bradycardia,
hypertension with a widening pulse pressure, and irregular (Cheyne-Stokes) respirations.
2. The nurse is administering Mannitol to a patient with increased ICP. Which monitoring
parameter is the priority to prevent a common complication of this medication?
A. Serum glucose levels
B. Deep tendon reflexes
C. Breath sounds for crackles
D. Peripheral pulses
, Answer: C
Rationale: Mannitol is an osmotic diuretic that pulls fluid into the vascular space. A major
complication is fluid volume overload and pulmonary edema; therefore, monitoring breath
sounds is critical.
3. A patient with a T4 spinal cord injury (SCI) reports a sudden, throbbing headache and has a
blood pressure of 190/100 mmHg. What is the nurse’s first action?
A. Place the patient in a high-Fowler’s position
B. Administer PRN Hydralazine intravenously
C. Check the patient’s urinary catheter for kinks
D. Notify the healthcare provider immediately
Answer: A
Rationale: The symptoms suggest Autonomic Dysreflexia. The priority action is to sit the
patient upright (high-Fowler’s) to lower blood pressure via orthostatic effect before
addressing the cause.
4. Which Glasgow Coma Scale (GCS) score would require the nurse to prepare for immediate
endotracheal intubation?
A. 12
B. 10
C. 8
