NSG 4100 (AHIII) EXAM 4 TESTBANK (UNITS 8,
9, 10) | QUESTIONS AND ANSWERS | 2026
UPDATE | 100% CORRECT | WITH COMPLETE
SOLUTIONS - GALEN.
SECTION 1: NEUROLOGICAL EMERGENCIES &
INCREASED ICP (Questions 1-25)
Question 1
The nurse caring for a client with a head injury would recognize
which assessment finding as early signs of increased ICP? (Select all
that apply)
A) Kussmaul breathing
B) Projectile vomiting
C) Weakness in one extremity
D) Headache not aggravated by movement of straining
E) Decreased urine output
F) Papilledema
Correct Answer: A, C, D
Rationale: Early signs of increased ICP include changes in level of
consciousness, headache (not aggravated by straining), focal deficits such as
weakness in one extremity, and Kussmaul breathing . Projectile vomiting and
papilledema are late signs, and decreased urine output is not a primary
indicator of increased ICP .
,Question 2
A nurse caring for a client diagnosed with a head injury. Which of
the following situations needs intervention by the nurse?
A) The padded side rails up
B) The bed is adjusted to low level
C) The client's spouse turns on the TV one hour in the afternoon and 3 hours
in the evening
D) The head of bed is elevated at 30 degree angle
Correct Answer: C
Rationale: A client with a head injury should be in a quiet, non-stimulating
environment to prevent further increases in ICP. Prolonged television viewing
(1 hour in the afternoon and 3 hours in the evening) is excessive stimulation
and requires intervention . The other options represent appropriate safety
and positioning measures .
Question 3
The critical care nurse is caring for a client with a head injury
secondary to a motorcycle accident who, on morning rounds, is
responsive to painful stimulus and assumes decorticate posturing.
Two hours later, which data would warrant immediate intervention
by the nurse?
A) The client has purposeful movement when the nurse rubs the sternum
B) The client extends the upper and lower extremities in response to painful
stimuli
C) The client is aimlessly thrashing in the bed when a noxious stimuli is
applied
Correct Answer: B
Rationale: Extensor posturing (decerebrate) indicates more severe brain
injury and worsening neurological status. This represents deterioration from
decorticate posturing and warrants immediate intervention . Purposeful
movement indicates improvement, while thrashing may indicate pain or
agitation .
,Question 4
The nurse is caring for clients in the ED. Which client should the
nurse assess first?
A) The client with an epidural hematoma
B) The client who had a seizure who is in the postictal state
C) The client diagnosed with R/O encephalitis who has a headache
D) The client with multiple sclerosis who has scanning speech
Correct Answer: A
Rationale: An epidural hematoma is a medical emergency caused by arterial
bleeding (typically from the middle meningeal artery) that requires
immediate surgical evacuation to prevent brain herniation . Delays can lead
to irreversible neurological damage or death .
Question 5
What would the nurse suspect when hourly assessment of urine
output on a post-craniotomy patient exhibits a urine output from a
catheter of 1,500 mL for 2 consecutive hours?
A) Rushing syndrome
B) Syndrome of inappropriate antidiuretic hormone (SIADH)
C) Adrenal crisis
D) Diabetes insipidus
Correct Answer: D
Rationale: Diabetes insipidus (DI) is a complication of increased ICP following
head trauma. It is characterized by excessive urine output (polyuria) with low
specific gravity . Vigilant monitoring of fluid balance is essential to manage
this complication .
, Question 6
A patient has developed diabetes insipidus after having increased
ICP following head trauma. What nursing assessment best
addresses this complication?
A) Vigilant monitoring of fluid balance
B) Continuous BP monitoring
C) Serial arterial blood gases (ABGs)
D) Monitoring of the patient's airway for patency
Correct Answer: A
Rationale: DI causes excessive fluid loss through polyuria, leading to
hypernatremia and dehydration. Vigilant monitoring of intake and output is
essential to maintain fluid and electrolyte balance .
Question 7
During the exam of an unconscious patient, the nurse observes that
the patient's pupils are fixed and dilated. What is the most plausible
clinical significance of the nurse's finding?
A) It suggests onset of metabolic problems
B) It indicates paralysis on the right side of the body
C) It indicates paralysis of cranial nerve X
D) It indicates an injury at the midbrain level
Correct Answer: D
Rationale: Fixed and dilated pupils indicate injury at the midbrain level,
specifically compression of the oculomotor nerve (CN III). This is a late sign
of increased ICP and a serious neurological emergency .
Question 8
9, 10) | QUESTIONS AND ANSWERS | 2026
UPDATE | 100% CORRECT | WITH COMPLETE
SOLUTIONS - GALEN.
SECTION 1: NEUROLOGICAL EMERGENCIES &
INCREASED ICP (Questions 1-25)
Question 1
The nurse caring for a client with a head injury would recognize
which assessment finding as early signs of increased ICP? (Select all
that apply)
A) Kussmaul breathing
B) Projectile vomiting
C) Weakness in one extremity
D) Headache not aggravated by movement of straining
E) Decreased urine output
F) Papilledema
Correct Answer: A, C, D
Rationale: Early signs of increased ICP include changes in level of
consciousness, headache (not aggravated by straining), focal deficits such as
weakness in one extremity, and Kussmaul breathing . Projectile vomiting and
papilledema are late signs, and decreased urine output is not a primary
indicator of increased ICP .
,Question 2
A nurse caring for a client diagnosed with a head injury. Which of
the following situations needs intervention by the nurse?
A) The padded side rails up
B) The bed is adjusted to low level
C) The client's spouse turns on the TV one hour in the afternoon and 3 hours
in the evening
D) The head of bed is elevated at 30 degree angle
Correct Answer: C
Rationale: A client with a head injury should be in a quiet, non-stimulating
environment to prevent further increases in ICP. Prolonged television viewing
(1 hour in the afternoon and 3 hours in the evening) is excessive stimulation
and requires intervention . The other options represent appropriate safety
and positioning measures .
Question 3
The critical care nurse is caring for a client with a head injury
secondary to a motorcycle accident who, on morning rounds, is
responsive to painful stimulus and assumes decorticate posturing.
Two hours later, which data would warrant immediate intervention
by the nurse?
A) The client has purposeful movement when the nurse rubs the sternum
B) The client extends the upper and lower extremities in response to painful
stimuli
C) The client is aimlessly thrashing in the bed when a noxious stimuli is
applied
Correct Answer: B
Rationale: Extensor posturing (decerebrate) indicates more severe brain
injury and worsening neurological status. This represents deterioration from
decorticate posturing and warrants immediate intervention . Purposeful
movement indicates improvement, while thrashing may indicate pain or
agitation .
,Question 4
The nurse is caring for clients in the ED. Which client should the
nurse assess first?
A) The client with an epidural hematoma
B) The client who had a seizure who is in the postictal state
C) The client diagnosed with R/O encephalitis who has a headache
D) The client with multiple sclerosis who has scanning speech
Correct Answer: A
Rationale: An epidural hematoma is a medical emergency caused by arterial
bleeding (typically from the middle meningeal artery) that requires
immediate surgical evacuation to prevent brain herniation . Delays can lead
to irreversible neurological damage or death .
Question 5
What would the nurse suspect when hourly assessment of urine
output on a post-craniotomy patient exhibits a urine output from a
catheter of 1,500 mL for 2 consecutive hours?
A) Rushing syndrome
B) Syndrome of inappropriate antidiuretic hormone (SIADH)
C) Adrenal crisis
D) Diabetes insipidus
Correct Answer: D
Rationale: Diabetes insipidus (DI) is a complication of increased ICP following
head trauma. It is characterized by excessive urine output (polyuria) with low
specific gravity . Vigilant monitoring of fluid balance is essential to manage
this complication .
, Question 6
A patient has developed diabetes insipidus after having increased
ICP following head trauma. What nursing assessment best
addresses this complication?
A) Vigilant monitoring of fluid balance
B) Continuous BP monitoring
C) Serial arterial blood gases (ABGs)
D) Monitoring of the patient's airway for patency
Correct Answer: A
Rationale: DI causes excessive fluid loss through polyuria, leading to
hypernatremia and dehydration. Vigilant monitoring of intake and output is
essential to maintain fluid and electrolyte balance .
Question 7
During the exam of an unconscious patient, the nurse observes that
the patient's pupils are fixed and dilated. What is the most plausible
clinical significance of the nurse's finding?
A) It suggests onset of metabolic problems
B) It indicates paralysis on the right side of the body
C) It indicates paralysis of cranial nerve X
D) It indicates an injury at the midbrain level
Correct Answer: D
Rationale: Fixed and dilated pupils indicate injury at the midbrain level,
specifically compression of the oculomotor nerve (CN III). This is a late sign
of increased ICP and a serious neurological emergency .
Question 8
