, RASMUSSEN NUR 2755 MULTIDIMENSIONAL CARE IV |
FINAL EXAM PREP AND STUDY GUIDE EXAM WITH
MULTIPLE CHOICE OF QUESTIONS AND CORRECT ANSWERS
ALREADY GRADED A+ AND 100% GUARANTEE PASS
1. A nurse is caring for a client with increased intracranial pressure (ICP).
Which assessment finding indicates Cushing’s triad?
A. Hypotension, tachycardia, and hyperthermia
B. Hypertension, bradycardia, and irregular respirations ✅
C. Hypotension, bradycardia, and regular respirations
D. Hypertension, tachycardia, and Cheyne-Stokes respirations
Rationale: Cushing’s triad is a late sign of increased ICP characterized by
hypertension (widened pulse pressure), bradycardia, and irregular
respirations (Cheyne-Stokes). It indicates impending brainstem herniation.
2. A client with a traumatic brain injury (TBI) has a Glasgow Coma Scale
(GCS) score of 8. What is the priority nursing action?
A. Document the score and continue monitoring
B. Prepare for intubation and mechanical ventilation ✅
C. Administer oral pain medication
D. Encourage family to stimulate the patient
Rationale: A GCS score of 8 or less indicates severe TBI and coma. Airway
protection is the priority, as these patients cannot protect their airway.
Intubation and mechanical ventilation are indicated when GCS ≤ 8.
3. A client with a spinal cord injury at T6 suddenly develops severe
hypertension, bradycardia, and a pounding headache. What is the most likely
diagnosis?
A. Autonomic dysreflexia ✅
B. Spinal shock
C. Neurogenic shock
FINAL EXAM PREP AND STUDY GUIDE EXAM WITH
MULTIPLE CHOICE OF QUESTIONS AND CORRECT ANSWERS
ALREADY GRADED A+ AND 100% GUARANTEE PASS
1. A nurse is caring for a client with increased intracranial pressure (ICP).
Which assessment finding indicates Cushing’s triad?
A. Hypotension, tachycardia, and hyperthermia
B. Hypertension, bradycardia, and irregular respirations ✅
C. Hypotension, bradycardia, and regular respirations
D. Hypertension, tachycardia, and Cheyne-Stokes respirations
Rationale: Cushing’s triad is a late sign of increased ICP characterized by
hypertension (widened pulse pressure), bradycardia, and irregular
respirations (Cheyne-Stokes). It indicates impending brainstem herniation.
2. A client with a traumatic brain injury (TBI) has a Glasgow Coma Scale
(GCS) score of 8. What is the priority nursing action?
A. Document the score and continue monitoring
B. Prepare for intubation and mechanical ventilation ✅
C. Administer oral pain medication
D. Encourage family to stimulate the patient
Rationale: A GCS score of 8 or less indicates severe TBI and coma. Airway
protection is the priority, as these patients cannot protect their airway.
Intubation and mechanical ventilation are indicated when GCS ≤ 8.
3. A client with a spinal cord injury at T6 suddenly develops severe
hypertension, bradycardia, and a pounding headache. What is the most likely
diagnosis?
A. Autonomic dysreflexia ✅
B. Spinal shock
C. Neurogenic shock
