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NSG 430 Adult Health Nursing II — Exam 3 Practice Questions
Complete (Verified Update!!!!!!!2026–2027)
Exam 3 Blueprint Coverage:
• Topic 10: Management of Acute Neurological Disorders
• Topic 11: Management of Acute Musculoskeletal Disorders
• Topic 12: Management of Critical Care & Multisystem Disorders
SECTION 1: NEUROLOGICAL DISORDERS (Questions)
Increased Intracranial Pressure (ICP) & Traumatic Brain Injury
1. A nurse is caring for a patient with a traumatic brain injury
who is showing signs of increased intracranial pressure (ICP).
Which of the following is the earliest indicator of a change in
neurological status?
A) A change in the level of consciousness
B) Dilation of the pupils
C) The presence of Cushing's triad
D) Decerebrate posturing
Correct Answer: A
Rationale: A change in the level of consciousness (LOC) is
considered the most sensitive and earliest sign of increased
intracranial pressure. This occurs because the brain's cortical
cells are highly sensitive to decreased oxygen and glucose
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delivery caused by rising pressure. Nurses must assess for
subtle changes such as restlessness, confusion, or increased
lethargy to intervene early.
2. A client with a traumatic brain injury is being monitored for
increased intracranial pressure (ICP). The nurse notes a blood
pressure of 160/90 mmHg, heart rate of 52 bpm, and irregular
respirations of 8 breaths per minute. Which finding requires the
most immediate intervention?
A) Blood pressure of 160/90 mmHg
B) Heart rate of 52 bpm
C) Irregular respirations of 8 breaths per minute
D) All of the above findings require equal priority
Correct Answer: C
Rationale: Irregular respirations of 8 breaths per minute
represent the most immediately life-threatening component of
Cushing's triad, as inadequate ventilation leads to hypercapnia,
cerebral vasodilation, and further increases in ICP. While
hypertension and bradycardia are also components of Cushing's
triad, the respiratory irregularity poses the most imminent risk
of respiratory arrest and brainstem herniation. The priority
intervention is to secure the airway, provide supplemental
oxygen, and prepare for possible mechanical ventilation to
prevent secondary brain injury.
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3. A nurse is preparing to administer Mannitol (Osmitrol) to a
patient with increased ICP. Which assessment is most
important to monitor the effectiveness of this medication?
A) Blood glucose levels
B) Increased urine output
C) Decreased body temperature
D) Deep tendon reflexes
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that works by
drawing fluid out of the brain tissue and into the vascular space
to reduce cerebral edema. Because it is a diuretic, the
effectiveness is evidenced by an increase in urine output and a
subsequent decrease in intracranial pressure. The nurse should
also monitor serum osmolality and electrolytes during
administration.
4. What is the normal range for intracranial pressure (ICP)?
A) 0–5 mmHg
B) 5–15 mmHg
C) 15–25 mmHg
D) 25–35 mmHg
Correct Answer: B
Rationale: Normal intracranial pressure is 5 to 15 mm Hg. ICP is
the pressure exerted by the cerebrospinal fluid within the
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ventricles of the brain. Elevated ICP (> 20 mm Hg) can lead to
cerebral ischemia and herniation if not treated promptly.
5. A nurse is caring for a patient with increased ICP. Which
position should the nurse maintain for this patient?
A) Supine with the head flat
B) Head of bed elevated to 30 degrees with head in neutral
alignment
C) Trendelenburg position
D) Prone position
Correct Answer: B
Rationale: Elevating the head of the bed to 30 degrees
promotes venous drainage from the brain while maintaining
cerebral perfusion pressure. The head should be kept in neutral
alignment to prevent jugular vein compression, which would
impair venous drainage and increase ICP.
6. Which of the following is a late sign of increased intracranial
pressure?
A) Restlessness
B) Confusion
C) Cushing's triad
D) Headache
Correct Answer: C
NSG 430 Adult Health Nursing II — Exam 3 Practice Questions
Complete (Verified Update!!!!!!!2026–2027)
Exam 3 Blueprint Coverage:
• Topic 10: Management of Acute Neurological Disorders
• Topic 11: Management of Acute Musculoskeletal Disorders
• Topic 12: Management of Critical Care & Multisystem Disorders
SECTION 1: NEUROLOGICAL DISORDERS (Questions)
Increased Intracranial Pressure (ICP) & Traumatic Brain Injury
1. A nurse is caring for a patient with a traumatic brain injury
who is showing signs of increased intracranial pressure (ICP).
Which of the following is the earliest indicator of a change in
neurological status?
A) A change in the level of consciousness
B) Dilation of the pupils
C) The presence of Cushing's triad
D) Decerebrate posturing
Correct Answer: A
Rationale: A change in the level of consciousness (LOC) is
considered the most sensitive and earliest sign of increased
intracranial pressure. This occurs because the brain's cortical
cells are highly sensitive to decreased oxygen and glucose
, Page |2
delivery caused by rising pressure. Nurses must assess for
subtle changes such as restlessness, confusion, or increased
lethargy to intervene early.
2. A client with a traumatic brain injury is being monitored for
increased intracranial pressure (ICP). The nurse notes a blood
pressure of 160/90 mmHg, heart rate of 52 bpm, and irregular
respirations of 8 breaths per minute. Which finding requires the
most immediate intervention?
A) Blood pressure of 160/90 mmHg
B) Heart rate of 52 bpm
C) Irregular respirations of 8 breaths per minute
D) All of the above findings require equal priority
Correct Answer: C
Rationale: Irregular respirations of 8 breaths per minute
represent the most immediately life-threatening component of
Cushing's triad, as inadequate ventilation leads to hypercapnia,
cerebral vasodilation, and further increases in ICP. While
hypertension and bradycardia are also components of Cushing's
triad, the respiratory irregularity poses the most imminent risk
of respiratory arrest and brainstem herniation. The priority
intervention is to secure the airway, provide supplemental
oxygen, and prepare for possible mechanical ventilation to
prevent secondary brain injury.
, Page |3
3. A nurse is preparing to administer Mannitol (Osmitrol) to a
patient with increased ICP. Which assessment is most
important to monitor the effectiveness of this medication?
A) Blood glucose levels
B) Increased urine output
C) Decreased body temperature
D) Deep tendon reflexes
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that works by
drawing fluid out of the brain tissue and into the vascular space
to reduce cerebral edema. Because it is a diuretic, the
effectiveness is evidenced by an increase in urine output and a
subsequent decrease in intracranial pressure. The nurse should
also monitor serum osmolality and electrolytes during
administration.
4. What is the normal range for intracranial pressure (ICP)?
A) 0–5 mmHg
B) 5–15 mmHg
C) 15–25 mmHg
D) 25–35 mmHg
Correct Answer: B
Rationale: Normal intracranial pressure is 5 to 15 mm Hg. ICP is
the pressure exerted by the cerebrospinal fluid within the
, Page |4
ventricles of the brain. Elevated ICP (> 20 mm Hg) can lead to
cerebral ischemia and herniation if not treated promptly.
5. A nurse is caring for a patient with increased ICP. Which
position should the nurse maintain for this patient?
A) Supine with the head flat
B) Head of bed elevated to 30 degrees with head in neutral
alignment
C) Trendelenburg position
D) Prone position
Correct Answer: B
Rationale: Elevating the head of the bed to 30 degrees
promotes venous drainage from the brain while maintaining
cerebral perfusion pressure. The head should be kept in neutral
alignment to prevent jugular vein compression, which would
impair venous drainage and increase ICP.
6. Which of the following is a late sign of increased intracranial
pressure?
A) Restlessness
B) Confusion
C) Cushing's triad
D) Headache
Correct Answer: C
