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NUR 417
Final Exam 2025: NUR 417 Care of Adult II
Actual Questions and Answers – Concordia
University St. Paul
1. what is the most sensitive and reliable indicator of neurologic status?: level
of consciousness (LOC)
2. why does increased ICP cause changes in vital signs?: increasing pressure
on thalamus, hypothalamus, pons, and medulla
3. what vital sign change is seen with increased ICP?: Cushing triad
4. what is Cushing triad?: systolic hypertension with a widening pulse
pressure bradycardia with a full, bounding pulse
irregular respirations
5. systolic hypertension: SBP >140 mmHg
6. what is a widening pulse pressure?: distance between SBP and DBP is
getting larger
NUR 417
,NUR 417
7. Cushing triad usually does not appear until...: ICP has been increased for
some time OR
is suddenly and markedly increased (EX: brain trauma)
8. Cushing triad is a...: medical emergency
9. Cushing triad is a sign of ____ and _____: brainstem compression;
impending death
10. Cushing triad is a sign of...: severely increased ICP
11. ocular signs of increased ICP include...: alterations in pupil size/reaction
to light blurred vision diplopia
changes in extraocular eye
movements papilledema
ptosis
12. what is diplopia?: double vision
13. what is papilledema?: swelling of the optic disc
14. what is ptosis?: drooping eyelid
NUR 417
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NUR 417
15. why is headache a manifestation of increased ICP?: compression of
intracranial structures
16. nocturnal headache and/or a headache in the morning may indicate...:
tumor OR
other space-occupying lesions
17. what kind of vomiting is a sign of increased ICP?: unexpected vomiting
18. what is unexpected vomiting?: vomiting not preceded with nausea
19. "head injury" includes...: any injury or trauma to the scalp, skull, or
brain
20. assessments for brain trauma: s/s increased ICP GCS
assess neuro status
determine if there is CSF leak
21. types of CSF leakage: rhinorrhea otorrhea
22. rhinorrhea: CSF leakage from the nose
23. otorrhea: CSF leakage from the ear
NUR 417
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24. how do you confirm that leakage is CSF?: test for presence of glucose
look for the "halo" or "ring sign"
25. what is spinal shock?: sudden, temporary loss or impairment of spinal
cord function below the level of injury
26. spinal shock occurs after...: acute spinal cord injury
27. what are the S/S of spinal shock?: loss of deep tendon and sphincter
reflexes
loss of sensation
flaccid paralysis below the level of injury
28. what are the S/S of neurogenic shock?: significant hypotension (<90
mmHg) bradycardia
temperature dysregulation (usually warm)
29. neurogenic shock causes...: peripheral vasodilation venous pooling
decreased CO
30. what is autonomic dysreflexia?: massive, uncompensated
cardiovascular reaction mediated by the SNS
NUR 417
NUR 417
Final Exam 2025: NUR 417 Care of Adult II
Actual Questions and Answers – Concordia
University St. Paul
1. what is the most sensitive and reliable indicator of neurologic status?: level
of consciousness (LOC)
2. why does increased ICP cause changes in vital signs?: increasing pressure
on thalamus, hypothalamus, pons, and medulla
3. what vital sign change is seen with increased ICP?: Cushing triad
4. what is Cushing triad?: systolic hypertension with a widening pulse
pressure bradycardia with a full, bounding pulse
irregular respirations
5. systolic hypertension: SBP >140 mmHg
6. what is a widening pulse pressure?: distance between SBP and DBP is
getting larger
NUR 417
,NUR 417
7. Cushing triad usually does not appear until...: ICP has been increased for
some time OR
is suddenly and markedly increased (EX: brain trauma)
8. Cushing triad is a...: medical emergency
9. Cushing triad is a sign of ____ and _____: brainstem compression;
impending death
10. Cushing triad is a sign of...: severely increased ICP
11. ocular signs of increased ICP include...: alterations in pupil size/reaction
to light blurred vision diplopia
changes in extraocular eye
movements papilledema
ptosis
12. what is diplopia?: double vision
13. what is papilledema?: swelling of the optic disc
14. what is ptosis?: drooping eyelid
NUR 417
, 3
NUR 417
15. why is headache a manifestation of increased ICP?: compression of
intracranial structures
16. nocturnal headache and/or a headache in the morning may indicate...:
tumor OR
other space-occupying lesions
17. what kind of vomiting is a sign of increased ICP?: unexpected vomiting
18. what is unexpected vomiting?: vomiting not preceded with nausea
19. "head injury" includes...: any injury or trauma to the scalp, skull, or
brain
20. assessments for brain trauma: s/s increased ICP GCS
assess neuro status
determine if there is CSF leak
21. types of CSF leakage: rhinorrhea otorrhea
22. rhinorrhea: CSF leakage from the nose
23. otorrhea: CSF leakage from the ear
NUR 417
, NUR 417
24. how do you confirm that leakage is CSF?: test for presence of glucose
look for the "halo" or "ring sign"
25. what is spinal shock?: sudden, temporary loss or impairment of spinal
cord function below the level of injury
26. spinal shock occurs after...: acute spinal cord injury
27. what are the S/S of spinal shock?: loss of deep tendon and sphincter
reflexes
loss of sensation
flaccid paralysis below the level of injury
28. what are the S/S of neurogenic shock?: significant hypotension (<90
mmHg) bradycardia
temperature dysregulation (usually warm)
29. neurogenic shock causes...: peripheral vasodilation venous pooling
decreased CO
30. what is autonomic dysreflexia?: massive, uncompensated
cardiovascular reaction mediated by the SNS
NUR 417
