NUR265 Exam 3 Actual Exam 2026/2027 |
Complete Exam-Style Questions with Detailed
Rationales | Pass Guaranteed – A+ Graded
SECTION 1: Traumatic Brain Injury (TBI) & Increased Intracranial Pressure (ICP)
Q1: A nurse is assessing a patient who sustained a traumatic brain injury 4 hours ago.
Which finding indicates the earliest sign of neurologic deterioration?
A. Unequal pupil size
B. Decreased level of consciousness
C. Widened pulse pressure
D. Decorticate posturing
Correct Answer: B
Rationale: Correct because a decreased level of consciousness is the earliest indicator
of neurologic deterioration in a patient with TBI, as it reflects progressive brain injury
before other late signs appear.
Q2: A patient with increased intracranial pressure exhibits bradycardia, hypertension
with a widened pulse pressure, and irregular respirations. These findings indicate which
condition?
A. Neurogenic shock
B. Cushing's triad
C. Normal compensatory mechanism
D. Impending brain death
Correct Answer: B
Rationale: Correct because Cushing's triad consists of bradycardia, hypertension with a
widened pulse pressure, and irregular respirations, which are late signs of critically
increased intracranial pressure and require immediate intervention.
Q3: A patient admitted with a traumatic brain injury has a Glasgow Coma Scale score of
6. The nurse interprets this finding as indicating:
A. Mild brain injury
B. Moderate brain injury
C. Coma
D. Full recovery potential
,Correct Answer: C
Rationale: Correct because a Glasgow Coma Scale score of 7 or less indicates coma,
and a score of 6 reflects severe impairment of consciousness requiring intensive
monitoring and intervention.
Q4: When caring for a patient with traumatic brain injury, which nursing intervention is
essential to prevent increased intracranial pressure?
A. Cluster care activities to allow for rest periods
B. Maintain the head and neck in a midline neutral position
C. Encourage deep breathing and coughing every 2 hours
D. Suction the airway frequently without preoxygenation
Correct Answer: B
Rationale: Correct because maintaining the head and neck in a midline neutral position
promotes venous drainage from the brain and prevents obstruction of jugular venous
return, which helps prevent further increases in intracranial pressure.
Q5: A patient with traumatic brain injury requires endotracheal suctioning. Which action
should the nurse take to minimize the risk of increased intracranial pressure?
A. Limit suctioning to 30 seconds per pass
B. Hyperoxygenate the patient before and after suctioning
C. Avoid suctioning unless absolutely necessary
D. Use a straight catheter without lubrication
Correct Answer: B
Rationale: Correct because hyperoxygenating before and after suctioning prevents
hypoxia, which can cause cerebral vasodilation and further increase intracranial
pressure in patients with traumatic brain injury.
Q6: A patient with a basilar skull fracture has clear nasal drainage. The nurse suspects a
cerebrospinal fluid leak. Which test should the nurse perform?
A. Glucose oxidase test on the drainage
B. Halo sign test
C. Specific gravity test
D. Culture and sensitivity
Correct Answer: B
, Rationale: Correct because the halo sign test detects cerebrospinal fluid by observing a
ring formation around a blood clot on gauze, which occurs when CSF separates from
blood and indicates a dural tear.
Q7: A patient with a basilar skull fracture becomes irritable and restless. What is the
nurse's priority action?
A. Apply soft restraints for safety
B. Administer a sedative as ordered
C. Follow up with the primary healthcare provider immediately
D. Increase environmental stimulation
Correct Answer: C
Rationale: Correct because irritability and restlessness in a patient with a basilar skull
fracture indicate potential neurologic deterioration, and immediate follow-up with the
primary healthcare provider is the priority to prevent further complications.
Q8: Which clinical findings are consistent with a mild traumatic brain injury?
A. Hemiparesis and aphasia
B. Amnesia, dizziness, and sensitivity to light and noise
C. Coma and decerebrate posturing
D. Seizures and projectile vomiting
Correct Answer: B
Rationale: Correct because amnesia, dizziness, and sensitivity to light and noise are
classic symptoms of a mild traumatic brain injury or concussion, whereas the other
options indicate more severe brain injury.
Q9: Which patient population is at the greatest risk for traumatic brain injury?
A. Adolescents ages 13-19
B. Young adults ages 20-35
C. Older adults with sensory deficits
D. Infants under 12 months
Correct Answer: C
Rationale: Correct because older adults, particularly those with sensory deficits such as
macular degeneration that increase fall risk, have the highest incidence of traumatic
brain injury due to age-related physiologic changes and increased vulnerability.
Complete Exam-Style Questions with Detailed
Rationales | Pass Guaranteed – A+ Graded
SECTION 1: Traumatic Brain Injury (TBI) & Increased Intracranial Pressure (ICP)
Q1: A nurse is assessing a patient who sustained a traumatic brain injury 4 hours ago.
Which finding indicates the earliest sign of neurologic deterioration?
A. Unequal pupil size
B. Decreased level of consciousness
C. Widened pulse pressure
D. Decorticate posturing
Correct Answer: B
Rationale: Correct because a decreased level of consciousness is the earliest indicator
of neurologic deterioration in a patient with TBI, as it reflects progressive brain injury
before other late signs appear.
Q2: A patient with increased intracranial pressure exhibits bradycardia, hypertension
with a widened pulse pressure, and irregular respirations. These findings indicate which
condition?
A. Neurogenic shock
B. Cushing's triad
C. Normal compensatory mechanism
D. Impending brain death
Correct Answer: B
Rationale: Correct because Cushing's triad consists of bradycardia, hypertension with a
widened pulse pressure, and irregular respirations, which are late signs of critically
increased intracranial pressure and require immediate intervention.
Q3: A patient admitted with a traumatic brain injury has a Glasgow Coma Scale score of
6. The nurse interprets this finding as indicating:
A. Mild brain injury
B. Moderate brain injury
C. Coma
D. Full recovery potential
,Correct Answer: C
Rationale: Correct because a Glasgow Coma Scale score of 7 or less indicates coma,
and a score of 6 reflects severe impairment of consciousness requiring intensive
monitoring and intervention.
Q4: When caring for a patient with traumatic brain injury, which nursing intervention is
essential to prevent increased intracranial pressure?
A. Cluster care activities to allow for rest periods
B. Maintain the head and neck in a midline neutral position
C. Encourage deep breathing and coughing every 2 hours
D. Suction the airway frequently without preoxygenation
Correct Answer: B
Rationale: Correct because maintaining the head and neck in a midline neutral position
promotes venous drainage from the brain and prevents obstruction of jugular venous
return, which helps prevent further increases in intracranial pressure.
Q5: A patient with traumatic brain injury requires endotracheal suctioning. Which action
should the nurse take to minimize the risk of increased intracranial pressure?
A. Limit suctioning to 30 seconds per pass
B. Hyperoxygenate the patient before and after suctioning
C. Avoid suctioning unless absolutely necessary
D. Use a straight catheter without lubrication
Correct Answer: B
Rationale: Correct because hyperoxygenating before and after suctioning prevents
hypoxia, which can cause cerebral vasodilation and further increase intracranial
pressure in patients with traumatic brain injury.
Q6: A patient with a basilar skull fracture has clear nasal drainage. The nurse suspects a
cerebrospinal fluid leak. Which test should the nurse perform?
A. Glucose oxidase test on the drainage
B. Halo sign test
C. Specific gravity test
D. Culture and sensitivity
Correct Answer: B
, Rationale: Correct because the halo sign test detects cerebrospinal fluid by observing a
ring formation around a blood clot on gauze, which occurs when CSF separates from
blood and indicates a dural tear.
Q7: A patient with a basilar skull fracture becomes irritable and restless. What is the
nurse's priority action?
A. Apply soft restraints for safety
B. Administer a sedative as ordered
C. Follow up with the primary healthcare provider immediately
D. Increase environmental stimulation
Correct Answer: C
Rationale: Correct because irritability and restlessness in a patient with a basilar skull
fracture indicate potential neurologic deterioration, and immediate follow-up with the
primary healthcare provider is the priority to prevent further complications.
Q8: Which clinical findings are consistent with a mild traumatic brain injury?
A. Hemiparesis and aphasia
B. Amnesia, dizziness, and sensitivity to light and noise
C. Coma and decerebrate posturing
D. Seizures and projectile vomiting
Correct Answer: B
Rationale: Correct because amnesia, dizziness, and sensitivity to light and noise are
classic symptoms of a mild traumatic brain injury or concussion, whereas the other
options indicate more severe brain injury.
Q9: Which patient population is at the greatest risk for traumatic brain injury?
A. Adolescents ages 13-19
B. Young adults ages 20-35
C. Older adults with sensory deficits
D. Infants under 12 months
Correct Answer: C
Rationale: Correct because older adults, particularly those with sensory deficits such as
macular degeneration that increase fall risk, have the highest incidence of traumatic
brain injury due to age-related physiologic changes and increased vulnerability.
