NUR 445: EXAM 3 REVIEW (#3)
QUESTIONS AND ANSWERS
2026/2026
What is intracranial pressure? - ANSWERSWhen pressure inside the skull dramatically
increases.
Name some factors that can increase ICP. - ANSWERS- Hypoxia
- Hypercapnia
- Hyperthermia
- TBI's
- Hemorrhage
What should the nurse ask clients with ICP? - ANSWERS- When was their last bowel
movement
- Any noticed signs or symptoms of infection
- Any noise drainage
- How is their intake and output?
Name one of the earliest signs of ICP. - ANSWERSMental status change- Restless,
agitated, confused.
Name five other early signs of ICP. - ANSWERS- Double vision, swelling of the optic
nerve, dilated pupils, unequal
- Positive Babinski reflex
- Decorticate or decerebrate posturing
- Seizure, headache, vomiting WITHOUT nausea
- Deterioration of motor function
Describe decerebrate posture. - ANSWERSAn abnormal body posture that involves the
arms and legs being held straight out, the toes being pointed downward, and the head
and neck being arched backward.
What are three late signs of intracranial pressure? - ANSWERS- Irregular breathing:
Cheyne's stokes
- Unconscious
- Cushing Triad: Increase in BP and decrease in HR, RR
Describe pneumothorax. - ANSWERSAir enters the pleural space, disrupts negative
pressure, and causes the lung to collapse.
Note: This is also known as collapsed lung.
, What are three common causes of a pneumothorax? - ANSWERS- Blunt force trauma:
Gunshot wound, stabbing.
- Medical procedures: Central line placement, thoracentesis.
- Mechanical ventilation: Too much PEEP
What are six signs of pneumothorax? - ANSWERS- Sudden chest pain
- Cyanosis
- Unequal chest expansion
- Use of accessory muscles
- Dyspnea: Low O2 and BP. High HR
- Absent breath sounds
What is the difference between open and closed pneumothorax? - ANSWERS- Open:
Penetrating thoracic injury that causes air to enter from the outside in.
- Closed: Air enters the pleural space without an outside wound.
Describe a tension pneumothorax. - ANSWERSWorsening of a pneumothorax where air
accumulates so much and cannot escape-- Increased intrathoracic pressure.
When caring for a client was a chest tube, what would you want to see in their room? -
ANSWERS- Chest tube below the chest
- Sterile water
- Vaseline (occlusive) gauze
- Clamps
Tension Pneumothorax: How does the body try to compensate? - ANSWERSIncreased
breathing, but the heart would have nothing to pump. Therefore, there would be an
increase in HR and decrease in CO2 and BP.
Name one common treatment of pneumothorax. - ANSWERSChest tube insertion.
What is the hallmark sign of (tension) pneumothorax? - ANSWERSTracheal deviation
Note: LIFE-THREATENING
What are five nursing considerations regarding chest tubes? - ANSWERS- Keep the
drainage system below the insertion site
- Tubing must be free of kinks
- Monitor lung sounds, RR, and dyspnea
- Assess for subcutaneous emphysema (crackling found on palpation of the skin)
What happens if chest tube is dislodged? - ANSWERSCover insertion site on 3 sides
and notify MD!
QUESTIONS AND ANSWERS
2026/2026
What is intracranial pressure? - ANSWERSWhen pressure inside the skull dramatically
increases.
Name some factors that can increase ICP. - ANSWERS- Hypoxia
- Hypercapnia
- Hyperthermia
- TBI's
- Hemorrhage
What should the nurse ask clients with ICP? - ANSWERS- When was their last bowel
movement
- Any noticed signs or symptoms of infection
- Any noise drainage
- How is their intake and output?
Name one of the earliest signs of ICP. - ANSWERSMental status change- Restless,
agitated, confused.
Name five other early signs of ICP. - ANSWERS- Double vision, swelling of the optic
nerve, dilated pupils, unequal
- Positive Babinski reflex
- Decorticate or decerebrate posturing
- Seizure, headache, vomiting WITHOUT nausea
- Deterioration of motor function
Describe decerebrate posture. - ANSWERSAn abnormal body posture that involves the
arms and legs being held straight out, the toes being pointed downward, and the head
and neck being arched backward.
What are three late signs of intracranial pressure? - ANSWERS- Irregular breathing:
Cheyne's stokes
- Unconscious
- Cushing Triad: Increase in BP and decrease in HR, RR
Describe pneumothorax. - ANSWERSAir enters the pleural space, disrupts negative
pressure, and causes the lung to collapse.
Note: This is also known as collapsed lung.
, What are three common causes of a pneumothorax? - ANSWERS- Blunt force trauma:
Gunshot wound, stabbing.
- Medical procedures: Central line placement, thoracentesis.
- Mechanical ventilation: Too much PEEP
What are six signs of pneumothorax? - ANSWERS- Sudden chest pain
- Cyanosis
- Unequal chest expansion
- Use of accessory muscles
- Dyspnea: Low O2 and BP. High HR
- Absent breath sounds
What is the difference between open and closed pneumothorax? - ANSWERS- Open:
Penetrating thoracic injury that causes air to enter from the outside in.
- Closed: Air enters the pleural space without an outside wound.
Describe a tension pneumothorax. - ANSWERSWorsening of a pneumothorax where air
accumulates so much and cannot escape-- Increased intrathoracic pressure.
When caring for a client was a chest tube, what would you want to see in their room? -
ANSWERS- Chest tube below the chest
- Sterile water
- Vaseline (occlusive) gauze
- Clamps
Tension Pneumothorax: How does the body try to compensate? - ANSWERSIncreased
breathing, but the heart would have nothing to pump. Therefore, there would be an
increase in HR and decrease in CO2 and BP.
Name one common treatment of pneumothorax. - ANSWERSChest tube insertion.
What is the hallmark sign of (tension) pneumothorax? - ANSWERSTracheal deviation
Note: LIFE-THREATENING
What are five nursing considerations regarding chest tubes? - ANSWERS- Keep the
drainage system below the insertion site
- Tubing must be free of kinks
- Monitor lung sounds, RR, and dyspnea
- Assess for subcutaneous emphysema (crackling found on palpation of the skin)
What happens if chest tube is dislodged? - ANSWERSCover insertion site on 3 sides
and notify MD!
