NUR 417 Nursing Care of the Adult II
NUR 417 FINAL EXAM LATEST 2026
SUMMER SEMESTER Concordia St.
Paul |COMPLETE QUESTIONS AND
ANSWERS |GRADED A+
A patient who is suspected of having an epidural hematoma is admitted to the
emergency
department. Which of the following actions should the nurse plan to take?
a. Administer IV furosemide.
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANS: D
The principal treatment for epidural hematoma is rapid surgery to remove the
hematoma and
prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide
or highdose barbiturate therapy may be needed, but these will not be of benefit unless
the hematoma
is removed. Minimal blood loss occurs with head injuries, and transfusion is usually
not
necessary
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of
the
following findings should the nurse expect to observe?
a. Judgement changes
b. Expressive aphasia
c. Right-sided weakness
d. Difficulty swallowing
ANS: A
The frontal lobes control intellectual activities such as judgement. Speech is controlled
in the
parietal lobe. Weakness and hemiplegia occur on the contralateral side from the
tumour.
Swallowing is controlled by the brain stem.
,NUR 417 Nursing Care of the Adult II
Which of the following statements by a patient who is being discharged from the
emergency department (ED) after a head injury indicates a need for intervention by the
nurse?
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go to bed."
c. "I do not even remember being in an accident."
d. "I can take acetaminophen for my headache."
ANS: B Following a head injury, the patient should avoid operating heavy machinery.
Retrograde amnesia is common after a concussion. The patient can take
acetaminophen for headache and should return if symptoms of increased intracranial
pressure such as dizziness or nausea occur
The nurse is caring for a patient who is disoriented and anxious as result of increased
intracranial pressure. Which of the following nursing actions should be included in the
plan of
care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input
ANS: A
Patients with disorientation as result of increased ICP will be calmed by the presence
of
someone familiar at the bedside. Restraints should be avoided because they increase
agitation
and anxiety. The patient requires frequent assessment for complications; the use of
touch and a
soothing voice will decrease anxiety for most patients. The patient will have
photophobia, so
the light should be dim.
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial
pressure
(ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
,NUR 417 Nursing Care of the Adult II
ANS: C
The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP=
MAPICP), below the normal of 70-100 mm Hg and approaching the level of ischemia
and
neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral
perfusion.
Immediate changes in the patient's therapy such as fluid infusion or vasopressor
administration are needed to improve the cerebral perfusion pressure. Adjustments in
the head
elevation should only be done after consulting with the health care provider. Continued
monitoring and documentation also will be done, but they are not the first actions that
the
nurse should take.
The nurse is suctioning a patient with a traumatic head injury and notes that the
intracranial
pressure has increased from 14 to 16 mm Hg. Which of the following actions should the
nurse
take first?
a. Document the increase in intracranial pressure.
b. Assure that the patient's neck is not in a flexed position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol infusion.
ANS: B
Since suctioning will cause a transient increase in intracranial pressure, the nurse
should
initially check for other factors that might be contributing to the increase and observe
the
patient for a few minutes. Documentation is needed, but this is not the first action.
There is no
need to notify the health care provider about this expected reaction to suctioning.
Propofol is
used to control patient anxiety or agitation; there is no indication that anxiety has
contributed
to the increase in intracranial pressure.
After receiving change of shift report, which of the following patients should the nurse
assess first?
a. A 44-year-old receiving IV antibiotics for meningococcal meningitis
, NUR 417 Nursing Care of the Adult II
b. A 23-year-old who had a skull fracture and craniotomy the previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head
injury a week ago
d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy
ANS: D
The patient that should be seen first is the one that requires the closest monitoring—
the
patient with ICP and receiving hyperventilation therapy. The postcraniotomy patient,
patient
with an ICP monitor, and the patient on IV antibiotics should be assessed as well but
the
priority would be the most critically ill patients.
The nurse is caring for a patient with possible cerebral edema who has a serum
sodium level
of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which
of the
following prescribed interventions should the nurse implement first?
a. Draw blood for arterial blood gases (ABGs).
b. Administer 5% hypertonic saline intravenously.
c. Administer acetaminophen 650 mg orally.
d. Send patient for computed tomography (CT) of the head.
ANS: B The patient's low sodium indicates that hyponatremia may be causing the
cerebral edema, and the nurse's first action should be to correct the low sodium level.
Acetaminophen will have minimal effect on the headache because it is caused by
cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and
obtaining a CT scan may add some useful information, but the low sodium level may
lead to seizures unless it is addressed quickly.
After the emergency department nurse has received a status report on the following
patients
who have been admitted with head injuries, which patient should the nurse assess
first?
a. A patient whose cranial radiograph shows a linear skull fracture
b. A patient who has an initial Glasgow Coma Scale score of 13
c. A patient who lost consciousness for a few seconds after a fall
d. A patient whose right pupil is 10 mm and unresponsive to light
ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage, brain
NUR 417 FINAL EXAM LATEST 2026
SUMMER SEMESTER Concordia St.
Paul |COMPLETE QUESTIONS AND
ANSWERS |GRADED A+
A patient who is suspected of having an epidural hematoma is admitted to the
emergency
department. Which of the following actions should the nurse plan to take?
a. Administer IV furosemide.
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANS: D
The principal treatment for epidural hematoma is rapid surgery to remove the
hematoma and
prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide
or highdose barbiturate therapy may be needed, but these will not be of benefit unless
the hematoma
is removed. Minimal blood loss occurs with head injuries, and transfusion is usually
not
necessary
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of
the
following findings should the nurse expect to observe?
a. Judgement changes
b. Expressive aphasia
c. Right-sided weakness
d. Difficulty swallowing
ANS: A
The frontal lobes control intellectual activities such as judgement. Speech is controlled
in the
parietal lobe. Weakness and hemiplegia occur on the contralateral side from the
tumour.
Swallowing is controlled by the brain stem.
,NUR 417 Nursing Care of the Adult II
Which of the following statements by a patient who is being discharged from the
emergency department (ED) after a head injury indicates a need for intervention by the
nurse?
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go to bed."
c. "I do not even remember being in an accident."
d. "I can take acetaminophen for my headache."
ANS: B Following a head injury, the patient should avoid operating heavy machinery.
Retrograde amnesia is common after a concussion. The patient can take
acetaminophen for headache and should return if symptoms of increased intracranial
pressure such as dizziness or nausea occur
The nurse is caring for a patient who is disoriented and anxious as result of increased
intracranial pressure. Which of the following nursing actions should be included in the
plan of
care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input
ANS: A
Patients with disorientation as result of increased ICP will be calmed by the presence
of
someone familiar at the bedside. Restraints should be avoided because they increase
agitation
and anxiety. The patient requires frequent assessment for complications; the use of
touch and a
soothing voice will decrease anxiety for most patients. The patient will have
photophobia, so
the light should be dim.
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial
pressure
(ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
,NUR 417 Nursing Care of the Adult II
ANS: C
The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP=
MAPICP), below the normal of 70-100 mm Hg and approaching the level of ischemia
and
neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral
perfusion.
Immediate changes in the patient's therapy such as fluid infusion or vasopressor
administration are needed to improve the cerebral perfusion pressure. Adjustments in
the head
elevation should only be done after consulting with the health care provider. Continued
monitoring and documentation also will be done, but they are not the first actions that
the
nurse should take.
The nurse is suctioning a patient with a traumatic head injury and notes that the
intracranial
pressure has increased from 14 to 16 mm Hg. Which of the following actions should the
nurse
take first?
a. Document the increase in intracranial pressure.
b. Assure that the patient's neck is not in a flexed position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol infusion.
ANS: B
Since suctioning will cause a transient increase in intracranial pressure, the nurse
should
initially check for other factors that might be contributing to the increase and observe
the
patient for a few minutes. Documentation is needed, but this is not the first action.
There is no
need to notify the health care provider about this expected reaction to suctioning.
Propofol is
used to control patient anxiety or agitation; there is no indication that anxiety has
contributed
to the increase in intracranial pressure.
After receiving change of shift report, which of the following patients should the nurse
assess first?
a. A 44-year-old receiving IV antibiotics for meningococcal meningitis
, NUR 417 Nursing Care of the Adult II
b. A 23-year-old who had a skull fracture and craniotomy the previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head
injury a week ago
d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy
ANS: D
The patient that should be seen first is the one that requires the closest monitoring—
the
patient with ICP and receiving hyperventilation therapy. The postcraniotomy patient,
patient
with an ICP monitor, and the patient on IV antibiotics should be assessed as well but
the
priority would be the most critically ill patients.
The nurse is caring for a patient with possible cerebral edema who has a serum
sodium level
of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which
of the
following prescribed interventions should the nurse implement first?
a. Draw blood for arterial blood gases (ABGs).
b. Administer 5% hypertonic saline intravenously.
c. Administer acetaminophen 650 mg orally.
d. Send patient for computed tomography (CT) of the head.
ANS: B The patient's low sodium indicates that hyponatremia may be causing the
cerebral edema, and the nurse's first action should be to correct the low sodium level.
Acetaminophen will have minimal effect on the headache because it is caused by
cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and
obtaining a CT scan may add some useful information, but the low sodium level may
lead to seizures unless it is addressed quickly.
After the emergency department nurse has received a status report on the following
patients
who have been admitted with head injuries, which patient should the nurse assess
first?
a. A patient whose cranial radiograph shows a linear skull fracture
b. A patient who has an initial Glasgow Coma Scale score of 13
c. A patient who lost consciousness for a few seconds after a fall
d. A patient whose right pupil is 10 mm and unresponsive to light
ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage, brain
