NUR 265 Exam 3 Study Guide 2026 | TBI, ICP,
Spinal Cord Injury, Guillain-Barré, Myasthenia
Gravis, Burns, Shock & Sepsis | Galen College
of Nursing
NUR 265 Exam 3 Study Guide 2026 | TBI, ICP, Spinal Cord Injury, Guillain-Barré,
Myasthenia Gravis, Burns, Shock & Sepsis | Galen College of Nursing
SECTION 1: Traumatic Brain Injury (TBI)
1. A nurse is assessing a client with a suspected traumatic brain injury (TBI).
Which of the following findings indicates the need for immediate intervention?
A) Glasgow Coma Scale (GCS) score of 15
B) Pupils equal and reactive to light
C) GCS score of 8 or less
D) Complaint of mild headache
Correct Answer: C
Rationale: A GCS score of 8 or less indicates severe TBI and requires immediate
intervention, including airway protection and possible intubation. A GCS of 15 is
normal. Equal and reactive pupils are normal. A mild headache may be expected
but requires monitoring.
2. A student is studying the rotation of the head in a client with a suspected
cervical spine injury. Which action is contraindicated?
,A) Applying a cervical collar
B) Maintaining manual stabilization
C) Flexing the neck to open the airway
D) Logrolling the client
Correct Answer: C
Rationale: The rotation of the head and flexion of the neck are contraindicated in
clients with suspected cervical spine injury. Flexing the neck can cause further
spinal cord damage. Manual stabilization and cervical collar application are
appropriate. Logrolling maintains spinal alignment.
3. A nurse is caring for a client with a TBI who has a GCS score of 6. Which of the
following is the priority nursing action?
A) Administering pain medication
B) Preparing for intubation
C) Performing a neurological assessment
D) Elevating the head of the bed
Correct Answer: B
Rationale: A GCS score of 6 indicates severe TBI and impending airway
compromise. The priority is to prepare for intubation to protect the airway. Pain
medication, neurological assessment, and elevating the head of the bed are
important but secondary to airway management.
4. A student is studying the rotation of the pupils in a client with increased
intracranial pressure (ICP). Which finding is an early sign of increased ICP?
A) Fixed and dilated pupils
B) Sluggish pupil response
C) Pinpoint pupils
D) Equal and reactive pupils
,Correct Answer: B
Rationale: The rotation of the pupils and sluggish pupil response is an early sign of
increased ICP due to compression of the oculomotor nerve (CN III). Fixed and
dilated pupils are a late sign. Pinpoint pupils suggest opioid overdose. Equal and
reactive pupils are normal.
5. A nurse is assessing a client with a TBI. Which of the following findings
indicates a basilar skull fracture?
A) Battle's sign
B) Periorbital edema
C) Scalp laceration
D) Headache
Correct Answer: A
Rationale: Battle's sign (bruising behind the ear) is a classic sign of basilar skull
fracture. Periorbital edema (raccoon eyes) is another sign. Scalp laceration and
headache are nonspecific findings.
6. A student is studying the rotation of the brain within the skull during a TBI.
Which type of TBI involves bleeding between the dura mater and the skull?
A) Epidural hematoma
B) Subdural hematoma
C) Subarachnoid hemorrhage
D) Intracerebral hemorrhage
Correct Answer: A
Rationale: The rotation of the brain within the skull during a TBI: an epidural
hematoma involves bleeding between the dura mater and the skull, often due to a
middle meningeal artery tear. Subdural hematoma is between the dura and
arachnoid. Subarachnoid hemorrhage is in the subarachnoid space. Intracerebral
hemorrhage is within the brain tissue.
, 7. A nurse is caring for a client with a TBI who is receiving mannitol. Which of
the following findings indicates the medication is effective?
A) Increased urine output
B) Decreased urine output
C) Increased ICP
D) Decreased serum osmolality
Correct Answer: A
Rationale: Mannitol is an osmotic diuretic used to reduce ICP. Increased urine
output indicates the medication is working. Decreased urine output, increased ICP,
and decreased serum osmolality indicate ineffective treatment.
8. A student is studying the rotation of the cerebral spinal fluid (CSF) in a client
with a TBI. Which finding is consistent with CSF leak?
A) Clear drainage from the nose
B) Bloody drainage from the ear
C) Serosanguineous drainage from a scalp laceration
D) Purulent drainage from the nose
Correct Answer: A
Rationale: The rotation of the cerebral spinal fluid (CSF): clear drainage from the
nose (rhinorrhea) is consistent with a CSF leak. Bloody drainage from the ear
(otorrhea) may also indicate a CSF leak. Serosanguineous drainage from a scalp
laceration is expected. Purulent drainage suggests infection.
9. A nurse is assessing a client with a TBI. Which of the following findings
indicates Cushing's triad?
A) Hypertension, bradycardia, irregular respirations
B) Hypotension, tachycardia, tachypnea
Spinal Cord Injury, Guillain-Barré, Myasthenia
Gravis, Burns, Shock & Sepsis | Galen College
of Nursing
NUR 265 Exam 3 Study Guide 2026 | TBI, ICP, Spinal Cord Injury, Guillain-Barré,
Myasthenia Gravis, Burns, Shock & Sepsis | Galen College of Nursing
SECTION 1: Traumatic Brain Injury (TBI)
1. A nurse is assessing a client with a suspected traumatic brain injury (TBI).
Which of the following findings indicates the need for immediate intervention?
A) Glasgow Coma Scale (GCS) score of 15
B) Pupils equal and reactive to light
C) GCS score of 8 or less
D) Complaint of mild headache
Correct Answer: C
Rationale: A GCS score of 8 or less indicates severe TBI and requires immediate
intervention, including airway protection and possible intubation. A GCS of 15 is
normal. Equal and reactive pupils are normal. A mild headache may be expected
but requires monitoring.
2. A student is studying the rotation of the head in a client with a suspected
cervical spine injury. Which action is contraindicated?
,A) Applying a cervical collar
B) Maintaining manual stabilization
C) Flexing the neck to open the airway
D) Logrolling the client
Correct Answer: C
Rationale: The rotation of the head and flexion of the neck are contraindicated in
clients with suspected cervical spine injury. Flexing the neck can cause further
spinal cord damage. Manual stabilization and cervical collar application are
appropriate. Logrolling maintains spinal alignment.
3. A nurse is caring for a client with a TBI who has a GCS score of 6. Which of the
following is the priority nursing action?
A) Administering pain medication
B) Preparing for intubation
C) Performing a neurological assessment
D) Elevating the head of the bed
Correct Answer: B
Rationale: A GCS score of 6 indicates severe TBI and impending airway
compromise. The priority is to prepare for intubation to protect the airway. Pain
medication, neurological assessment, and elevating the head of the bed are
important but secondary to airway management.
4. A student is studying the rotation of the pupils in a client with increased
intracranial pressure (ICP). Which finding is an early sign of increased ICP?
A) Fixed and dilated pupils
B) Sluggish pupil response
C) Pinpoint pupils
D) Equal and reactive pupils
,Correct Answer: B
Rationale: The rotation of the pupils and sluggish pupil response is an early sign of
increased ICP due to compression of the oculomotor nerve (CN III). Fixed and
dilated pupils are a late sign. Pinpoint pupils suggest opioid overdose. Equal and
reactive pupils are normal.
5. A nurse is assessing a client with a TBI. Which of the following findings
indicates a basilar skull fracture?
A) Battle's sign
B) Periorbital edema
C) Scalp laceration
D) Headache
Correct Answer: A
Rationale: Battle's sign (bruising behind the ear) is a classic sign of basilar skull
fracture. Periorbital edema (raccoon eyes) is another sign. Scalp laceration and
headache are nonspecific findings.
6. A student is studying the rotation of the brain within the skull during a TBI.
Which type of TBI involves bleeding between the dura mater and the skull?
A) Epidural hematoma
B) Subdural hematoma
C) Subarachnoid hemorrhage
D) Intracerebral hemorrhage
Correct Answer: A
Rationale: The rotation of the brain within the skull during a TBI: an epidural
hematoma involves bleeding between the dura mater and the skull, often due to a
middle meningeal artery tear. Subdural hematoma is between the dura and
arachnoid. Subarachnoid hemorrhage is in the subarachnoid space. Intracerebral
hemorrhage is within the brain tissue.
, 7. A nurse is caring for a client with a TBI who is receiving mannitol. Which of
the following findings indicates the medication is effective?
A) Increased urine output
B) Decreased urine output
C) Increased ICP
D) Decreased serum osmolality
Correct Answer: A
Rationale: Mannitol is an osmotic diuretic used to reduce ICP. Increased urine
output indicates the medication is working. Decreased urine output, increased ICP,
and decreased serum osmolality indicate ineffective treatment.
8. A student is studying the rotation of the cerebral spinal fluid (CSF) in a client
with a TBI. Which finding is consistent with CSF leak?
A) Clear drainage from the nose
B) Bloody drainage from the ear
C) Serosanguineous drainage from a scalp laceration
D) Purulent drainage from the nose
Correct Answer: A
Rationale: The rotation of the cerebral spinal fluid (CSF): clear drainage from the
nose (rhinorrhea) is consistent with a CSF leak. Bloody drainage from the ear
(otorrhea) may also indicate a CSF leak. Serosanguineous drainage from a scalp
laceration is expected. Purulent drainage suggests infection.
9. A nurse is assessing a client with a TBI. Which of the following findings
indicates Cushing's triad?
A) Hypertension, bradycardia, irregular respirations
B) Hypotension, tachycardia, tachypnea
