NURSING 202 EXAM 3 | COMPREHENSIVE STUDY GUIDE, NCLEX-STYLE PRACTICE QUESTIONS
AND ANSWERS 2026/2027
A nurse is caring for a client who has increased ICP and a new prescription for mannitol
(Osmitrol). For which of the following adverse effects should the nurse monitor?
A.) Hyperglycemia
B.) Hyponatremia
C.) Hypervolemia
D.) Oliguria - ANS ✔✔B.) Hyponatremia
A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16-22
mmHg. Which of the following actions should the nurse take to decrease the potential for
raising the client's ICP? (Select all that apply.)
A.) Suction the endotracheal tube.
B.) Hyperventilate the client.
C.) Elevate the client's head on two pillows.
D.) Administer a stool softener.
E.) Keep the client well hydrated. - ANS ✔✔B.) Hyperventilate the client (Hyperventilating the
client will prevent hypercarbia, which can cause vasodilation)
D.) Administer a stool softener (Administration of a stool softener will decrease the need to bear
down (Valsalva maneuver) during bowel movements, which can increase ICP.)
Patient's eyes are open and the patient is speaking to you as you are examining them. The
patient is speaking normally and answering questions appropriately. The patient is able to
follow commands like "show me two fingers". - ANS ✔✔GCS - 15
The patient's eyes remain closed, even if someone calls loudly. However, the patient will open
eyes if pinched. The patient states "don't" or "stop" when pinched, but does not speak in whole
sentences and does not answer any questions. The patient does not follow any commands, but
if pinched, will quickly push the nurse's hand away. - ANS ✔✔GCS - 10
,The patient has their eyes closed at first, but opens them if their name is called loudly. The
patient does not say any recognizable words. When asked a question, the patient looks
confused and says, "mmm?" without opening their mouth. The patient does not follow
commands, but if pinched, they pull away. - ANS ✔✔GCS - 9
Patient's eyes remain closed, even when pinched. The patient does not make any sounds, even
if pinched, and he/she does not follow commands. Finally, the patient will not moved, even if
pinched. - ANS ✔✔GCS - 3
Patient's eyes are open and looking at you while you are examining them. Speech is clear, but
confused. The patient does not know what happened to them and states the wrong month
when asked the date. The patient is slow to follow commands when asked to show two fingers,
but is still able to do so. - ANS ✔✔GCS - 14
The patient's eyes remain closed, even when pinched. He/she groans in response to being
pinched, but does not say any recognizable words. The patient does not follow any commands,
but if pinched will try to push the nurse's hand away. - ANS ✔✔GCS - 8
The patient's eyes will open and will be looking around with an anxious expression on their face.
The patient will not answer any questions at all. If pinched the patient will groan, but does not
say any recognizable words. The patient does not follow any commands, but if pinched will
quickly push the nurse's hand away. - ANS ✔✔GCS - 11
The patient's eyes will be closed, but will open briefly if someone calls to them loudly. The
patient will not answer any questions. If pinched, the patient will groan or yell, but does not say
any recognizable words. The patient does not follow any commands, but if pinched will quickly
push the nurse's hand away. - ANS ✔✔GCS - 10
The patient's eyes are closed, but will open them if someone speaks to them. The patient can
speak normally, but is confused. The patient does not remember exactly what happened to
,them, and gives the wrong month when asked the date. The patient is slow to follow commands
such as, "show me two fingers", but they are able to do so. - ANS ✔✔GCS - 13
The patient's eyes are closed even if someone talks to them or pinches them. The patient
answers questions correctly. The patient states that "his head hurts". When asked to open eyes,
the patient refuses stating, "the light makes my eyes hurt really bad." The patient follows
commands appropriately, but does not open eyes when doing so. - ANS ✔✔GCS - 12
A nurse is caring for a client who has just been admitted following surgical evacuation of a
subdural hematoma. Which of the following is the priority assessment?
A.) Glasgow Coma Scale
B.) Cranial nerve function
C.) Oxygen saturation
D.) Pupillary response - ANS ✔✔C.) Oxygen saturation
A nurse is caring for a client who was recently admitted to the emergency department following
a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of
22/min, and has a laceration of his forehead that is bleeding. Which of the following is the
priority nursing action at this time? - ANS ✔✔A.) Keep neck stabilized
A nures in the critical care unit is completing an admission assessment of a client who has a
gunshot wound to the head. Which of the following assessment findings are indicative of
increased ICP? (Select all that apply.)
A.) Headache
B.) Dilated pupils
C.) Tachycardia
D.) Decorticate posturing
E.) Hypotension - ANS ✔✔A.) Headache
B.) Dilated pupils
, D.) Decorticate posturing
A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis
laboratory findings should the nurse anticipate?
A.) Absence of glucose
B.) Decreased specific gravity
C.) Presence of ketones
D.) Presence of red blood cells (RBCs) - ANS ✔✔C.) Presence of ketones
A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of
the following statements by the client requires further teaching?
A.) "I can drink up to 2 quarts of fluid a day."
B.) "I should expect to urinate frequently at night."
C.) "I may experience headaches."
D.) "I may experience dry mouth." - ANS ✔✔A.) "I can drink up to 2 quarts of fluid a day."
(Excessive thirst is a manifestation of DI. So, consumption of up to 4-30 liters per day can be
expected and fluid intake should not be limited.)
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH).
Which of the following findings should the nurse expect? (Select all that apply.)
A.) Decreased serum sodium
B.) Urine specific gravity 1.001
C.) Serum osmolality 230 mOsm/L
D.) Polyuria
E.) Increased thirst - ANS ✔✔B.) Urine specific gravity 1.001 (urine of a client with DI will be
dilute with a low specific gravity, so less than 1.005)
AND ANSWERS 2026/2027
A nurse is caring for a client who has increased ICP and a new prescription for mannitol
(Osmitrol). For which of the following adverse effects should the nurse monitor?
A.) Hyperglycemia
B.) Hyponatremia
C.) Hypervolemia
D.) Oliguria - ANS ✔✔B.) Hyponatremia
A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16-22
mmHg. Which of the following actions should the nurse take to decrease the potential for
raising the client's ICP? (Select all that apply.)
A.) Suction the endotracheal tube.
B.) Hyperventilate the client.
C.) Elevate the client's head on two pillows.
D.) Administer a stool softener.
E.) Keep the client well hydrated. - ANS ✔✔B.) Hyperventilate the client (Hyperventilating the
client will prevent hypercarbia, which can cause vasodilation)
D.) Administer a stool softener (Administration of a stool softener will decrease the need to bear
down (Valsalva maneuver) during bowel movements, which can increase ICP.)
Patient's eyes are open and the patient is speaking to you as you are examining them. The
patient is speaking normally and answering questions appropriately. The patient is able to
follow commands like "show me two fingers". - ANS ✔✔GCS - 15
The patient's eyes remain closed, even if someone calls loudly. However, the patient will open
eyes if pinched. The patient states "don't" or "stop" when pinched, but does not speak in whole
sentences and does not answer any questions. The patient does not follow any commands, but
if pinched, will quickly push the nurse's hand away. - ANS ✔✔GCS - 10
,The patient has their eyes closed at first, but opens them if their name is called loudly. The
patient does not say any recognizable words. When asked a question, the patient looks
confused and says, "mmm?" without opening their mouth. The patient does not follow
commands, but if pinched, they pull away. - ANS ✔✔GCS - 9
Patient's eyes remain closed, even when pinched. The patient does not make any sounds, even
if pinched, and he/she does not follow commands. Finally, the patient will not moved, even if
pinched. - ANS ✔✔GCS - 3
Patient's eyes are open and looking at you while you are examining them. Speech is clear, but
confused. The patient does not know what happened to them and states the wrong month
when asked the date. The patient is slow to follow commands when asked to show two fingers,
but is still able to do so. - ANS ✔✔GCS - 14
The patient's eyes remain closed, even when pinched. He/she groans in response to being
pinched, but does not say any recognizable words. The patient does not follow any commands,
but if pinched will try to push the nurse's hand away. - ANS ✔✔GCS - 8
The patient's eyes will open and will be looking around with an anxious expression on their face.
The patient will not answer any questions at all. If pinched the patient will groan, but does not
say any recognizable words. The patient does not follow any commands, but if pinched will
quickly push the nurse's hand away. - ANS ✔✔GCS - 11
The patient's eyes will be closed, but will open briefly if someone calls to them loudly. The
patient will not answer any questions. If pinched, the patient will groan or yell, but does not say
any recognizable words. The patient does not follow any commands, but if pinched will quickly
push the nurse's hand away. - ANS ✔✔GCS - 10
The patient's eyes are closed, but will open them if someone speaks to them. The patient can
speak normally, but is confused. The patient does not remember exactly what happened to
,them, and gives the wrong month when asked the date. The patient is slow to follow commands
such as, "show me two fingers", but they are able to do so. - ANS ✔✔GCS - 13
The patient's eyes are closed even if someone talks to them or pinches them. The patient
answers questions correctly. The patient states that "his head hurts". When asked to open eyes,
the patient refuses stating, "the light makes my eyes hurt really bad." The patient follows
commands appropriately, but does not open eyes when doing so. - ANS ✔✔GCS - 12
A nurse is caring for a client who has just been admitted following surgical evacuation of a
subdural hematoma. Which of the following is the priority assessment?
A.) Glasgow Coma Scale
B.) Cranial nerve function
C.) Oxygen saturation
D.) Pupillary response - ANS ✔✔C.) Oxygen saturation
A nurse is caring for a client who was recently admitted to the emergency department following
a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of
22/min, and has a laceration of his forehead that is bleeding. Which of the following is the
priority nursing action at this time? - ANS ✔✔A.) Keep neck stabilized
A nures in the critical care unit is completing an admission assessment of a client who has a
gunshot wound to the head. Which of the following assessment findings are indicative of
increased ICP? (Select all that apply.)
A.) Headache
B.) Dilated pupils
C.) Tachycardia
D.) Decorticate posturing
E.) Hypotension - ANS ✔✔A.) Headache
B.) Dilated pupils
, D.) Decorticate posturing
A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis
laboratory findings should the nurse anticipate?
A.) Absence of glucose
B.) Decreased specific gravity
C.) Presence of ketones
D.) Presence of red blood cells (RBCs) - ANS ✔✔C.) Presence of ketones
A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of
the following statements by the client requires further teaching?
A.) "I can drink up to 2 quarts of fluid a day."
B.) "I should expect to urinate frequently at night."
C.) "I may experience headaches."
D.) "I may experience dry mouth." - ANS ✔✔A.) "I can drink up to 2 quarts of fluid a day."
(Excessive thirst is a manifestation of DI. So, consumption of up to 4-30 liters per day can be
expected and fluid intake should not be limited.)
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH).
Which of the following findings should the nurse expect? (Select all that apply.)
A.) Decreased serum sodium
B.) Urine specific gravity 1.001
C.) Serum osmolality 230 mOsm/L
D.) Polyuria
E.) Increased thirst - ANS ✔✔B.) Urine specific gravity 1.001 (urine of a client with DI will be
dilute with a low specific gravity, so less than 1.005)
