NUR 265 Exam 3 | Advanced Concepts of Medical-Surgical
Nursing (2026) Q&A | Galen College
1. A patient with a spinal cord injury at the T6 level develops a severe headache and a blood
pressure of 210/110 mmHg. What is the priority nursing action?
A) Administer antihypertensive medication
B) Place the patient in a supine position
C) Assess for a distended bladder or bowel impaction
D) Notify the provider immediately
Correct Answer: C) Assess for a distended bladder or bowel impaction
Rationale: Autonomic dysreflexia is a life-threatening emergency characterized by severe
hypertension and headache in patients with spinal cord injuries at or above T6. The priority is to
identify and remove the triggering stimulus, such as a distended bladder or bowel impaction,
before administering medications.
2. A nurse is assessing a patient with increased intracranial pressure. Which finding is most
concerning?
A) Headache that is worse in the morning
B) Nausea and vomiting
C) Seizure activity
D) Papilledema
Correct Answer: D) Papilledema
,Rationale: Papilledema (swelling of the optic disc) indicates increased intracranial pressure and
possible herniation. This requires immediate evaluation and intervention.
3. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8. Which finding is
most consistent with this score?
A) The patient opens eyes to pain, makes incomprehensible sounds, and withdraws from pain
B) The patient opens eyes spontaneously, is confused, and obeys commands
C) The patient opens eyes to speech, is oriented, and localizes pain
D) The patient does not open eyes, makes no sounds, and has no motor response
Correct Answer: A) The patient opens eyes to pain, makes incomprehensible sounds, and
withdraws from pain
Rationale: A GCS of 8 indicates severe brain injury. Eye opening to pain is 2, incomprehensible
sounds is 2, and withdrawal from pain is 4, totaling 8. A score of 8 or less indicates a severe
head injury requiring immediate intervention.
4. A patient with a suspected brain tumor reports a headache that is worse in the morning.
Which finding is most concerning?
A) Headache that is worse in the morning
B) Nausea and vomiting
C) Seizure activity
D) Papilledema
Correct Answer: D) Papilledema
,Rationale: Papilledema (swelling of the optic disc) indicates increased intracranial pressure and
possible herniation. This requires immediate evaluation and intervention.
5. A patient with increased intracranial pressure is scheduled for a lumbar puncture. Which
finding should the nurse report before the procedure?
A) Fever
B) Headache
C) Signs of increased ICP
D) Nausea
Correct Answer: C) Signs of increased ICP
Rationale: Lumbar puncture is contraindicated in the presence of increased intracranial pressure
because it can cause herniation. Signs of increased ICP must be reported before the procedure.
6. A patient with a spinal cord injury at the T6 level is experiencing a severe headache and has a
blood pressure of 210/110 mmHg. What is the priority nursing action?
A) Administer antihypertensive medication
B) Place the patient in a supine position
C) Assess for a distended bladder or bowel impaction
D) Notify the provider immediately
Correct Answer: C) Assess for a distended bladder or bowel impaction
Rationale: Autonomic dysreflexia is a life-threatening emergency characterized by severe
hypertension and headache in patients with spinal cord injuries at or above T6. The priority is to
, identify and remove the triggering stimulus, such as a distended bladder or bowel impaction,
before administering medications.
7. A patient with a new colostomy has a stoma that appears dark purplish. What is the nurse's
priority action?
A) Document the finding as normal
B) Notify the surgeon immediately
C) Apply a warm compress
D) Reassure the patient
Correct Answer: B) Notify the surgeon immediately
Rationale: A dark purplish stoma indicates compromised blood flow (ischemia) and is a surgical
emergency. This finding requires immediate notification of the surgeon. A healthy stoma should
be bright red and moist.
8. Which finding indicates a healthy stoma?
A) Pale and dry
B) Bright red and moist
C) Dark purple and swollen
D) Yellow and crusted
Correct Answer: B) Bright red and moist
Rationale: A healthy stoma is bright red and moist, similar to the oral mucosa, due to its rich
blood supply. A pale, dark, or dry stoma may indicate poor circulation or other complications.
Nursing (2026) Q&A | Galen College
1. A patient with a spinal cord injury at the T6 level develops a severe headache and a blood
pressure of 210/110 mmHg. What is the priority nursing action?
A) Administer antihypertensive medication
B) Place the patient in a supine position
C) Assess for a distended bladder or bowel impaction
D) Notify the provider immediately
Correct Answer: C) Assess for a distended bladder or bowel impaction
Rationale: Autonomic dysreflexia is a life-threatening emergency characterized by severe
hypertension and headache in patients with spinal cord injuries at or above T6. The priority is to
identify and remove the triggering stimulus, such as a distended bladder or bowel impaction,
before administering medications.
2. A nurse is assessing a patient with increased intracranial pressure. Which finding is most
concerning?
A) Headache that is worse in the morning
B) Nausea and vomiting
C) Seizure activity
D) Papilledema
Correct Answer: D) Papilledema
,Rationale: Papilledema (swelling of the optic disc) indicates increased intracranial pressure and
possible herniation. This requires immediate evaluation and intervention.
3. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8. Which finding is
most consistent with this score?
A) The patient opens eyes to pain, makes incomprehensible sounds, and withdraws from pain
B) The patient opens eyes spontaneously, is confused, and obeys commands
C) The patient opens eyes to speech, is oriented, and localizes pain
D) The patient does not open eyes, makes no sounds, and has no motor response
Correct Answer: A) The patient opens eyes to pain, makes incomprehensible sounds, and
withdraws from pain
Rationale: A GCS of 8 indicates severe brain injury. Eye opening to pain is 2, incomprehensible
sounds is 2, and withdrawal from pain is 4, totaling 8. A score of 8 or less indicates a severe
head injury requiring immediate intervention.
4. A patient with a suspected brain tumor reports a headache that is worse in the morning.
Which finding is most concerning?
A) Headache that is worse in the morning
B) Nausea and vomiting
C) Seizure activity
D) Papilledema
Correct Answer: D) Papilledema
,Rationale: Papilledema (swelling of the optic disc) indicates increased intracranial pressure and
possible herniation. This requires immediate evaluation and intervention.
5. A patient with increased intracranial pressure is scheduled for a lumbar puncture. Which
finding should the nurse report before the procedure?
A) Fever
B) Headache
C) Signs of increased ICP
D) Nausea
Correct Answer: C) Signs of increased ICP
Rationale: Lumbar puncture is contraindicated in the presence of increased intracranial pressure
because it can cause herniation. Signs of increased ICP must be reported before the procedure.
6. A patient with a spinal cord injury at the T6 level is experiencing a severe headache and has a
blood pressure of 210/110 mmHg. What is the priority nursing action?
A) Administer antihypertensive medication
B) Place the patient in a supine position
C) Assess for a distended bladder or bowel impaction
D) Notify the provider immediately
Correct Answer: C) Assess for a distended bladder or bowel impaction
Rationale: Autonomic dysreflexia is a life-threatening emergency characterized by severe
hypertension and headache in patients with spinal cord injuries at or above T6. The priority is to
, identify and remove the triggering stimulus, such as a distended bladder or bowel impaction,
before administering medications.
7. A patient with a new colostomy has a stoma that appears dark purplish. What is the nurse's
priority action?
A) Document the finding as normal
B) Notify the surgeon immediately
C) Apply a warm compress
D) Reassure the patient
Correct Answer: B) Notify the surgeon immediately
Rationale: A dark purplish stoma indicates compromised blood flow (ischemia) and is a surgical
emergency. This finding requires immediate notification of the surgeon. A healthy stoma should
be bright red and moist.
8. Which finding indicates a healthy stoma?
A) Pale and dry
B) Bright red and moist
C) Dark purple and swollen
D) Yellow and crusted
Correct Answer: B) Bright red and moist
Rationale: A healthy stoma is bright red and moist, similar to the oral mucosa, due to its rich
blood supply. A pale, dark, or dry stoma may indicate poor circulation or other complications.
