,NU 189 Final Exam | Questions & Verified
Answers | 2026 Edition | Galen College
1. The nurse is caring for a patient with suspected increased intracranial pressure (ICP). Which
assessment finding is the earliest and most sensitive indicator of this condition?
A) A widening pulse pressure
B) A change in level of consciousness, such as lethargy
C) Bradycardia with a bounding pulse
D) Irregular respirations with Cheyne-Stokes pattern
Correct Answer: A change in level of consciousness, such as lethargy
Rationale: A change in level of consciousness, including lethargy, confusion, or delayed responses, is the
earliest and most sensitive indicator of rising ICP. Cushing's triad (hypertension, bradycardia, irregular
respirations) is a late, ominous sign of brainstem compression.
2. A patient with a traumatic brain injury exhibits adduction of the arms and flexion of the elbows and
wrists in response to painful stimuli. The nurse correctly documents this as:
A) Decerebrate posturing
B) Decorticate posturing
C) Flaccid paralysis
D) Opisthotonos
Correct Answer: Decorticate posturing
Rationale: Decorticate (flexor) posturing is characterized by adduction of the arms and flexion of the
elbows and wrists, indicating damage to the cerebral hemispheres. Decerebrate posturing involves rigid
extension and suggests brainstem injury, which is a worse prognostic sign.
3. The nurse is caring for a patient who exhibits rigid extension and outward rotation of the arms and
legs in response to pain. This finding is consistent with:
,A) Decorticate posturing
B) Normal flexion withdrawal
C) Decerebrate posturing
D) Cushing's response
Correct Answer: Decerebrate posturing
Rationale: Decerebrate (extensor) posturing indicates severe brainstem damage and is a more serious
prognostic sign than decorticate posturing. It is characterized by rigid extension of all extremities.
4. A patient is admitted following an acute acetaminophen overdose. Within the first 24 hours, the nurse
should monitor for which early signs of toxicity?
A) Severe abdominal distention and jaundice
B) Hypertension and tachycardia
C) Confusion and stupor
D) Nausea, vomiting, and diaphoresis
Correct Answer: Nausea, vomiting, and diaphoresis
Rationale: Early signs of acetaminophen overdose (within 24 hours) include gastrointestinal distress and
diaphoresis. Signs of liver damage (right upper quadrant pain, jaundice, confusion) typically appear later,
after 24-48 hours.
5. A patient is receiving a blood transfusion and develops chills, fever, and low back pain. What is the
nurse's priority action?
A) Slow the transfusion rate and notify the provider
B) Stop the transfusion immediately and hang normal saline
C) Administer an antipyretic as prescribed
D) Document the reaction and continue the infusion
, Correct Answer: Stop the transfusion immediately and hang normal saline
Rationale: A transfusion reaction requires immediate cessation of the transfusion. The nurse must
maintain IV access with normal saline, which is the only compatible solution for blood products, before
notifying the provider and monitoring vital signs.
6. The nurse is reviewing a patient's laboratory results. The platelet count is 120,000/mm³. Which action
should the nurse take?
A) Document this as a normal finding
B) Initiate bleeding precautions
C) Administer a platelet transfusion without an order
D) Encourage the patient to ambulate frequently
Correct Answer: Initiate bleeding precautions
Rationale: A platelet count below 150,000/mm³ indicates thrombocytopenia. The nurse should
implement bleeding precautions, which include using a soft toothbrush, an electric razor, and avoiding
intramuscular injections.
7. A patient has a serum potassium level of 3.2 mEq/L. Which assessment finding would the nurse
expect?
A) Peaked T waves on ECG
B) Muscle weakness and hyporeflexia
C) Tetany and positive Chvostek's sign
D) Bradycardia
Correct Answer: Muscle weakness and hyporeflexia
Rationale: Hypokalemia (potassium < 3.5 mEq/L) causes skeletal muscle weakness, smooth muscle
slowing, and decreased deep tendon reflexes. Peaked T waves are seen in hyperkalemia, and tetany
occurs with hypocalcemia.
Answers | 2026 Edition | Galen College
1. The nurse is caring for a patient with suspected increased intracranial pressure (ICP). Which
assessment finding is the earliest and most sensitive indicator of this condition?
A) A widening pulse pressure
B) A change in level of consciousness, such as lethargy
C) Bradycardia with a bounding pulse
D) Irregular respirations with Cheyne-Stokes pattern
Correct Answer: A change in level of consciousness, such as lethargy
Rationale: A change in level of consciousness, including lethargy, confusion, or delayed responses, is the
earliest and most sensitive indicator of rising ICP. Cushing's triad (hypertension, bradycardia, irregular
respirations) is a late, ominous sign of brainstem compression.
2. A patient with a traumatic brain injury exhibits adduction of the arms and flexion of the elbows and
wrists in response to painful stimuli. The nurse correctly documents this as:
A) Decerebrate posturing
B) Decorticate posturing
C) Flaccid paralysis
D) Opisthotonos
Correct Answer: Decorticate posturing
Rationale: Decorticate (flexor) posturing is characterized by adduction of the arms and flexion of the
elbows and wrists, indicating damage to the cerebral hemispheres. Decerebrate posturing involves rigid
extension and suggests brainstem injury, which is a worse prognostic sign.
3. The nurse is caring for a patient who exhibits rigid extension and outward rotation of the arms and
legs in response to pain. This finding is consistent with:
,A) Decorticate posturing
B) Normal flexion withdrawal
C) Decerebrate posturing
D) Cushing's response
Correct Answer: Decerebrate posturing
Rationale: Decerebrate (extensor) posturing indicates severe brainstem damage and is a more serious
prognostic sign than decorticate posturing. It is characterized by rigid extension of all extremities.
4. A patient is admitted following an acute acetaminophen overdose. Within the first 24 hours, the nurse
should monitor for which early signs of toxicity?
A) Severe abdominal distention and jaundice
B) Hypertension and tachycardia
C) Confusion and stupor
D) Nausea, vomiting, and diaphoresis
Correct Answer: Nausea, vomiting, and diaphoresis
Rationale: Early signs of acetaminophen overdose (within 24 hours) include gastrointestinal distress and
diaphoresis. Signs of liver damage (right upper quadrant pain, jaundice, confusion) typically appear later,
after 24-48 hours.
5. A patient is receiving a blood transfusion and develops chills, fever, and low back pain. What is the
nurse's priority action?
A) Slow the transfusion rate and notify the provider
B) Stop the transfusion immediately and hang normal saline
C) Administer an antipyretic as prescribed
D) Document the reaction and continue the infusion
, Correct Answer: Stop the transfusion immediately and hang normal saline
Rationale: A transfusion reaction requires immediate cessation of the transfusion. The nurse must
maintain IV access with normal saline, which is the only compatible solution for blood products, before
notifying the provider and monitoring vital signs.
6. The nurse is reviewing a patient's laboratory results. The platelet count is 120,000/mm³. Which action
should the nurse take?
A) Document this as a normal finding
B) Initiate bleeding precautions
C) Administer a platelet transfusion without an order
D) Encourage the patient to ambulate frequently
Correct Answer: Initiate bleeding precautions
Rationale: A platelet count below 150,000/mm³ indicates thrombocytopenia. The nurse should
implement bleeding precautions, which include using a soft toothbrush, an electric razor, and avoiding
intramuscular injections.
7. A patient has a serum potassium level of 3.2 mEq/L. Which assessment finding would the nurse
expect?
A) Peaked T waves on ECG
B) Muscle weakness and hyporeflexia
C) Tetany and positive Chvostek's sign
D) Bradycardia
Correct Answer: Muscle weakness and hyporeflexia
Rationale: Hypokalemia (potassium < 3.5 mEq/L) causes skeletal muscle weakness, smooth muscle
slowing, and decreased deep tendon reflexes. Peaked T waves are seen in hyperkalemia, and tetany
occurs with hypocalcemia.
