NUR 2755 – Multidimensional Care IV (MDC
4) Exam 3 Questions with Answers|
Rasmussen University| Updated| Pass
Guaranteed
1. A patient with a traumatic brain injury becomes increasingly restless and confused. Which
action should the nurse take first?
A. Administer a prescribed sedative
B. Assess the patient's airway and oxygenation
C. Reorient the patient to time and place
D. Encourage oral fluids
Correct Answer: B. Assess the patient's airway and oxygenation
Rationale: Restlessness and confusion may indicate hypoxemia or neurological deterioration.
The nurse should first assess airway and oxygenation because inadequate oxygen delivery can
cause secondary brain injury.
2. Which finding is most concerning in a patient with increased intracranial pressure?
A. Mild headache
B. Photophobia
C. Decreasing level of consciousness
D. Nausea after medication
Correct Answer: C. Decreasing level of consciousness
Rationale: A declining level of consciousness is a major indicator of worsening neurological
function and potentially increasing intracranial pressure.
3. A patient with a head injury develops hypertension, bradycardia, and irregular respirations.
How should the nurse interpret these findings?
A. Hypovolemic shock
B. Cushing response
C. Neurogenic shock
D. Septic shock
,Correct Answer: B. Cushing response
Rationale: The combination of hypertension, bradycardia, and abnormal respirations is
associated with increased intracranial pressure and possible brainstem compression.
4. Which intervention is appropriate for a patient with increased intracranial pressure?
A. Keep the head of bed flat
B. Maintain the head and neck in neutral alignment
C. Encourage frequent coughing
D. Place the patient in Trendelenburg position
Correct Answer: B. Maintain the head and neck in neutral alignment
Rationale: Neutral alignment promotes venous drainage from the brain. Excessive neck flexion
or rotation can impair cerebral venous return and increase intracranial pressure.
5. A patient with a suspected cervical spinal injury arrives in the emergency department.
What is the priority nursing action?
A. Assess bowel sounds
B. Stabilize the cervical spine
C. Obtain a dietary history
D. Encourage ambulation
Correct Answer: B. Stabilize the cervical spine
Rationale: Cervical immobilization helps prevent additional spinal cord injury until the cervical
spine has been evaluated.
6. Which assessment finding is characteristic of neurogenic shock?
A. Tachycardia and cool skin
B. Bradycardia and hypotension
C. Severe hypertension and tachycardia
D. Fever and bounding pulses
Correct Answer: B. Bradycardia and hypotension
,Rationale: Neurogenic shock results from loss of sympathetic vascular tone, producing
vasodilation, hypotension, and often bradycardia.
7. A patient with a spinal cord injury suddenly develops severe hypertension, headache, and
flushing above the level of injury. Which condition should the nurse suspect?
A. Spinal shock
B. Autonomic dysreflexia
C. Hypovolemic shock
D. Increased intracranial pressure
Correct Answer: B. Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a medical emergency that can occur after spinal cord injury,
commonly with lesions at or above T6. A noxious stimulus below the injury—often bladder or
bowel distention—can trigger severe hypertension.
8. What should the nurse do first for a patient experiencing autonomic dysreflexia?
A. Place the patient flat
B. Sit the patient upright
C. Encourage oral fluids
D. Apply a heating pad
Correct Answer: B. Sit the patient upright
Rationale: Sitting the patient upright helps lower blood pressure. The nurse should then rapidly
identify and remove the triggering stimulus.
9. Which finding suggests spinal shock rather than autonomic dysreflexia?
A. Severe hypertension
B. Bradycardia with hypertension
C. Flaccid paralysis and absent reflexes below the injury
D. Severe headache and sweating
Correct Answer: C. Flaccid paralysis and absent reflexes below the injury
Rationale: Spinal shock is characterized by temporary loss of motor, sensory, and reflex activity
below the level of spinal cord injury.
, 10. A patient with a cervical spinal cord injury has shallow respirations. What is the nurse's
priority?
A. Assess respiratory effort and oxygenation
B. Offer a high-protein meal
C. Assess bowel sounds
D. Begin passive range-of-motion exercises
Correct Answer: A. Assess respiratory effort and oxygenation
Rationale: High cervical spinal cord injuries can impair respiratory muscles. Respiratory
compromise is an immediate threat to life.
11. A patient arrives after a motor vehicle crash with unequal pupils. What should the nurse
do?
A. Document the finding as expected
B. Perform a focused neurological assessment and notify the provider
C. Give oral fluids
D. Encourage sleep
Correct Answer: B. Perform a focused neurological assessment and notify the provider
Rationale: New anisocoria may indicate neurological deterioration, increased intracranial
pressure, or expanding intracranial hemorrhage.
12. Which symptom is particularly concerning for an epidural hematoma?
A. Gradual improvement in headache
B. Brief loss of consciousness followed by a lucid interval and deterioration
C. Mild nausea after eating
D. Chronic back pain
Correct Answer: B. Brief loss of consciousness followed by a lucid interval and deterioration
Rationale: Epidural hematomas classically may involve an initial loss of consciousness followed
by a lucid interval and then rapid neurological deterioration.
4) Exam 3 Questions with Answers|
Rasmussen University| Updated| Pass
Guaranteed
1. A patient with a traumatic brain injury becomes increasingly restless and confused. Which
action should the nurse take first?
A. Administer a prescribed sedative
B. Assess the patient's airway and oxygenation
C. Reorient the patient to time and place
D. Encourage oral fluids
Correct Answer: B. Assess the patient's airway and oxygenation
Rationale: Restlessness and confusion may indicate hypoxemia or neurological deterioration.
The nurse should first assess airway and oxygenation because inadequate oxygen delivery can
cause secondary brain injury.
2. Which finding is most concerning in a patient with increased intracranial pressure?
A. Mild headache
B. Photophobia
C. Decreasing level of consciousness
D. Nausea after medication
Correct Answer: C. Decreasing level of consciousness
Rationale: A declining level of consciousness is a major indicator of worsening neurological
function and potentially increasing intracranial pressure.
3. A patient with a head injury develops hypertension, bradycardia, and irregular respirations.
How should the nurse interpret these findings?
A. Hypovolemic shock
B. Cushing response
C. Neurogenic shock
D. Septic shock
,Correct Answer: B. Cushing response
Rationale: The combination of hypertension, bradycardia, and abnormal respirations is
associated with increased intracranial pressure and possible brainstem compression.
4. Which intervention is appropriate for a patient with increased intracranial pressure?
A. Keep the head of bed flat
B. Maintain the head and neck in neutral alignment
C. Encourage frequent coughing
D. Place the patient in Trendelenburg position
Correct Answer: B. Maintain the head and neck in neutral alignment
Rationale: Neutral alignment promotes venous drainage from the brain. Excessive neck flexion
or rotation can impair cerebral venous return and increase intracranial pressure.
5. A patient with a suspected cervical spinal injury arrives in the emergency department.
What is the priority nursing action?
A. Assess bowel sounds
B. Stabilize the cervical spine
C. Obtain a dietary history
D. Encourage ambulation
Correct Answer: B. Stabilize the cervical spine
Rationale: Cervical immobilization helps prevent additional spinal cord injury until the cervical
spine has been evaluated.
6. Which assessment finding is characteristic of neurogenic shock?
A. Tachycardia and cool skin
B. Bradycardia and hypotension
C. Severe hypertension and tachycardia
D. Fever and bounding pulses
Correct Answer: B. Bradycardia and hypotension
,Rationale: Neurogenic shock results from loss of sympathetic vascular tone, producing
vasodilation, hypotension, and often bradycardia.
7. A patient with a spinal cord injury suddenly develops severe hypertension, headache, and
flushing above the level of injury. Which condition should the nurse suspect?
A. Spinal shock
B. Autonomic dysreflexia
C. Hypovolemic shock
D. Increased intracranial pressure
Correct Answer: B. Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a medical emergency that can occur after spinal cord injury,
commonly with lesions at or above T6. A noxious stimulus below the injury—often bladder or
bowel distention—can trigger severe hypertension.
8. What should the nurse do first for a patient experiencing autonomic dysreflexia?
A. Place the patient flat
B. Sit the patient upright
C. Encourage oral fluids
D. Apply a heating pad
Correct Answer: B. Sit the patient upright
Rationale: Sitting the patient upright helps lower blood pressure. The nurse should then rapidly
identify and remove the triggering stimulus.
9. Which finding suggests spinal shock rather than autonomic dysreflexia?
A. Severe hypertension
B. Bradycardia with hypertension
C. Flaccid paralysis and absent reflexes below the injury
D. Severe headache and sweating
Correct Answer: C. Flaccid paralysis and absent reflexes below the injury
Rationale: Spinal shock is characterized by temporary loss of motor, sensory, and reflex activity
below the level of spinal cord injury.
, 10. A patient with a cervical spinal cord injury has shallow respirations. What is the nurse's
priority?
A. Assess respiratory effort and oxygenation
B. Offer a high-protein meal
C. Assess bowel sounds
D. Begin passive range-of-motion exercises
Correct Answer: A. Assess respiratory effort and oxygenation
Rationale: High cervical spinal cord injuries can impair respiratory muscles. Respiratory
compromise is an immediate threat to life.
11. A patient arrives after a motor vehicle crash with unequal pupils. What should the nurse
do?
A. Document the finding as expected
B. Perform a focused neurological assessment and notify the provider
C. Give oral fluids
D. Encourage sleep
Correct Answer: B. Perform a focused neurological assessment and notify the provider
Rationale: New anisocoria may indicate neurological deterioration, increased intracranial
pressure, or expanding intracranial hemorrhage.
12. Which symptom is particularly concerning for an epidural hematoma?
A. Gradual improvement in headache
B. Brief loss of consciousness followed by a lucid interval and deterioration
C. Mild nausea after eating
D. Chronic back pain
Correct Answer: B. Brief loss of consciousness followed by a lucid interval and deterioration
Rationale: Epidural hematomas classically may involve an initial loss of consciousness followed
by a lucid interval and then rapid neurological deterioration.
