Rasmussen University NUR 2755 Module 3 (pdf) | 2026/2027 | MDC 4
Q&A | Nursing
1. A client with a traumatic brain injury has a blood pressure of 190/100 mm
Hg, a heart rate of 48 beats per minute, and irregular respirations. The nurse
should recognize this as:
A) Early signs of increased intracranial pressure
B) Cushing's triad, a late sign of increased intracranial pressure
C) Normal compensatory mechanisms
D) Signs of a stroke
Correct Answer: Cushing's triad, a late sign of increased intracranial pressure
Rationale: Cushing's triad—increasing systolic blood pressure with widening
pulse pressure, bradycardia, and irregular respirations—is a late sign of
increased ICP indicating impending brain herniation. This is a medical
emergency requiring immediate intervention.
2. A client is brought to the emergency department following a motor vehicle
accident. The nurse notes clear fluid draining from the client's nose and
periorbital ecchymosis. The nurse should suspect which injury?
A) Epidural hematoma
B) Subdural hematoma
C) Basilar skull fracture
D) Concussion
Correct Answer: Basilar skull fracture
Rationale: Clear fluid draining from the nose (CSF leak) and periorbital
ecchymosis (raccoon eyes) are classic signs of a basilar skull fracture.
,Battle's sign (bruising behind the ear) may also be present. This injury
requires immediate intervention to prevent meningitis.
3. A client with a spinal cord injury at T6 develops a severe headache,
hypertension, and diaphoresis. The nurse should suspect which
complication?
A) Neurogenic shock
B) Spinal shock
C) Autonomic dysreflexia
D) Orthostatic hypotension
Correct Answer: Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a life-threatening condition that occurs in
clients with spinal cord injuries at or above T6. It is characterized by severe
hypertension, throbbing headache, diaphoresis, and bradycardia. The most
common trigger is bladder distention.
4. The nurse is caring for a client who is experiencing status epilepticus.
Which medication should the nurse anticipate administering first?
A) Phenytoin
B) Lorazepam
C) Carbamazepine
D) Valproic acid
Correct Answer: Lorazepam
Rationale: Status epilepticus is continuous seizure activity lasting more than
5 minutes or recurrent seizures without regaining baseline consciousness.
,Lorazepam (a benzodiazepine) is the first-line treatment to rapidly stop
seizure activity.
5. A client with Alzheimer's disease is in the moderate stage. Which
manifestation would the nurse expect to find?
A) Complete dependence for all activities of daily living
B) Difficulty with problem-solving and memory loss that interferes with daily
activities
C) No memory impairment
D) Ability to live independently without assistance
Correct Answer: Difficulty with problem-solving and memory loss that
interferes with daily activities
Rationale: In the moderate stage of Alzheimer's disease, clients have
difficulty with problem-solving, memory loss that interferes with daily
activities, and may require assistance with some activities of daily living.
Complete dependence is characteristic of the severe/late stage.
6. The nurse is assessing a client with suspected meningitis. Which finding is
most characteristic of this condition?
A) Battle's sign and raccoon eyes
B) Kernig's sign and Brudzinski's sign
C) Hemiparesis and aphasia
D) Polyuria and polydipsia
Correct Answer: Kernig's sign and Brudzinski's sign
Rationale: Kernig's sign (pain and resistance when extending the leg with the
hip flexed) and Brudzinski's sign (involuntary flexion of the hips and knees
, when the neck is flexed) are classic signs of meningeal irritation in
meningitis.
7. The nurse is caring for a client with bacterial meningitis. Which type of
isolation precaution should the nurse implement?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions only
Correct Answer: Droplet precautions
Rationale: Bacterial meningitis is transmitted via respiratory droplets,
requiring droplet precautions. This includes a private room and mask for
healthcare workers. The nurse should also implement standard precautions.
8. A client with a spinal cord injury is experiencing neurogenic shock. Which
finding would the nurse expect?
A) Hypertension and tachycardia
B) Hypotension and bradycardia
C) Hypertension and bradycardia
D) Hypotension and tachycardia
Correct Answer: Hypotension and bradycardia
Rationale: Neurogenic shock is characterized by vasodilation, pooling of
blood, decreased cardiac output, and hypotension with bradycardia. It occurs
due to the loss of sympathetic nervous system tone. Treatment includes fluid
resuscitation and vasopressors.
Q&A | Nursing
1. A client with a traumatic brain injury has a blood pressure of 190/100 mm
Hg, a heart rate of 48 beats per minute, and irregular respirations. The nurse
should recognize this as:
A) Early signs of increased intracranial pressure
B) Cushing's triad, a late sign of increased intracranial pressure
C) Normal compensatory mechanisms
D) Signs of a stroke
Correct Answer: Cushing's triad, a late sign of increased intracranial pressure
Rationale: Cushing's triad—increasing systolic blood pressure with widening
pulse pressure, bradycardia, and irregular respirations—is a late sign of
increased ICP indicating impending brain herniation. This is a medical
emergency requiring immediate intervention.
2. A client is brought to the emergency department following a motor vehicle
accident. The nurse notes clear fluid draining from the client's nose and
periorbital ecchymosis. The nurse should suspect which injury?
A) Epidural hematoma
B) Subdural hematoma
C) Basilar skull fracture
D) Concussion
Correct Answer: Basilar skull fracture
Rationale: Clear fluid draining from the nose (CSF leak) and periorbital
ecchymosis (raccoon eyes) are classic signs of a basilar skull fracture.
,Battle's sign (bruising behind the ear) may also be present. This injury
requires immediate intervention to prevent meningitis.
3. A client with a spinal cord injury at T6 develops a severe headache,
hypertension, and diaphoresis. The nurse should suspect which
complication?
A) Neurogenic shock
B) Spinal shock
C) Autonomic dysreflexia
D) Orthostatic hypotension
Correct Answer: Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a life-threatening condition that occurs in
clients with spinal cord injuries at or above T6. It is characterized by severe
hypertension, throbbing headache, diaphoresis, and bradycardia. The most
common trigger is bladder distention.
4. The nurse is caring for a client who is experiencing status epilepticus.
Which medication should the nurse anticipate administering first?
A) Phenytoin
B) Lorazepam
C) Carbamazepine
D) Valproic acid
Correct Answer: Lorazepam
Rationale: Status epilepticus is continuous seizure activity lasting more than
5 minutes or recurrent seizures without regaining baseline consciousness.
,Lorazepam (a benzodiazepine) is the first-line treatment to rapidly stop
seizure activity.
5. A client with Alzheimer's disease is in the moderate stage. Which
manifestation would the nurse expect to find?
A) Complete dependence for all activities of daily living
B) Difficulty with problem-solving and memory loss that interferes with daily
activities
C) No memory impairment
D) Ability to live independently without assistance
Correct Answer: Difficulty with problem-solving and memory loss that
interferes with daily activities
Rationale: In the moderate stage of Alzheimer's disease, clients have
difficulty with problem-solving, memory loss that interferes with daily
activities, and may require assistance with some activities of daily living.
Complete dependence is characteristic of the severe/late stage.
6. The nurse is assessing a client with suspected meningitis. Which finding is
most characteristic of this condition?
A) Battle's sign and raccoon eyes
B) Kernig's sign and Brudzinski's sign
C) Hemiparesis and aphasia
D) Polyuria and polydipsia
Correct Answer: Kernig's sign and Brudzinski's sign
Rationale: Kernig's sign (pain and resistance when extending the leg with the
hip flexed) and Brudzinski's sign (involuntary flexion of the hips and knees
, when the neck is flexed) are classic signs of meningeal irritation in
meningitis.
7. The nurse is caring for a client with bacterial meningitis. Which type of
isolation precaution should the nurse implement?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions only
Correct Answer: Droplet precautions
Rationale: Bacterial meningitis is transmitted via respiratory droplets,
requiring droplet precautions. This includes a private room and mask for
healthcare workers. The nurse should also implement standard precautions.
8. A client with a spinal cord injury is experiencing neurogenic shock. Which
finding would the nurse expect?
A) Hypertension and tachycardia
B) Hypotension and bradycardia
C) Hypertension and bradycardia
D) Hypotension and tachycardia
Correct Answer: Hypotension and bradycardia
Rationale: Neurogenic shock is characterized by vasodilation, pooling of
blood, decreased cardiac output, and hypotension with bradycardia. It occurs
due to the loss of sympathetic nervous system tone. Treatment includes fluid
resuscitation and vasopressors.
