1 | Page
NUR 265 Exam 3 Comprehensive
Practice Exam Questions & Verified
Answers Updated 2026 Just Released
Pass Guaranteed
This practice exam covers the key concepts for NUR 265 Exam 3
including traumatic brain injury, increased intracranial pressure,
meningitis, encephalitis, myasthenia gravis, Guillain-Barre
syndrome, spinal cord injury, autonomic dysreflexia, burns, and
sepsis. Each question is followed by the correct answer and a
detailed rationale explaining the clinical reasoning and nursing
priorities.
PART 1: TRAUMATIC BRAIN INJURY AND INCREASED
INTRACRANIAL PRESSURE
Question 1
The nurse is caring for an adult client who was recently admitted with a
head injury following a motor vehicle crash. One hour ago the clients
vital signs were temperature 98.6 degrees Fahrenheit pulse 110
,2 | Page
respirations 26 blood pressure 128 over 68 mm Hg. Which of the
following findings is a priority for the nurse to follow up
A Pulse 90 respirations 32 blood pressure 130 over 72 mm Hg
B Pulse 120 respirations 26 blood pressure 110 over 70 mm Hg
C Pulse 56 respirations 14 blood pressure 166 over 52 mm Hg
D Pulse 64 respirations 30 blood pressure 148 over 78 mm Hg
Verified Answer: C
Rationale: Cushing's triad of bradycardia, irregular respirations, and
widening pulse pressure with hypertension is a classic sign of increased
intracranial pressure. This is a medical emergency that requires
immediate intervention. The pulse of 56 and blood pressure of 166 over
52 with respirations of 14 indicate ICP elevation and potential brain
herniation.
Question 2
The nurse is caring for a client who sustained a closed head injury, is
receiving mechanical ventilation, and is at risk for developing increased
intracranial pressure. Which of the following actions should the nurse
take when caring for this client
A Perform passive range of motion to the clients hips and knees
B Log roll the client during turning and repositioning
C Elevate the foot of the clients bed
D Notify the charge nurse if the clients PaCO2 decreases from 39 to 35
mm Hg
,3 | Page
Verified Answer: B
Rationale: Log rolling maintains spinal alignment and prevents sudden
movements that could increase ICP. The head of the bed should be
elevated to 30 to 45 degrees to promote venous drainage. Hip flexion
should be avoided as it increases intra-abdominal pressure and ICP.
Question 3
The newly hired nurse is caring for a client who was admitted 12 hours
ago with a traumatic brain injury, is intubated, and is at risk for
developing increased intracranial pressure. Which interventions should
the nurse include in the clients plan of care
A Avoid clustering client care activities
B Maintain the head in a flexed position
C Provide a quiet environment by limiting visitors
D Have the client cough and deep breathe every hour
E Hyperoxygenate the client before and after suctioning
F Avoid maintaining hips in a flexed position
Verified Answer: A, C, E, F
Rationale: Interventions to reduce ICP include avoiding clustering care
activities to prevent stimulation, providing a quiet environment,
hyperoxygenating before and after suctioning, and avoiding hip flexion.
The head should be maintained in a neutral position not flexed.
Coughing increases ICP and should be avoided.
Question 4
, 4 | Page
The nurse working in the intensive care unit is assessing a client who
sustained a basilar skull fracture 24 hours ago. It is most important to
follow up with the primary health care provider if the client
A Becomes irritable and restless
B Has bruises under the eyes
C Is unable to name the state capital
D Reports having a persistent headache since admission
Verified Answer: A
Rationale: Irritability and restlessness may indicate increasing ICP or
neurological deterioration. Bruising under the eyes raccoon eyes is
expected with basilar skull fracture. A persistent headache is expected. A
change in level of consciousness or orientation is a priority finding.
Question 5
The nurse is assessing a client who has experienced a mild traumatic
brain injury. Which findings are consistent with this diagnosis
A Dizziness and gait problems
B A widened pulse pressure
C Increased sensitivity to light or noise
D A Glasgow Coma Scale score of 9
E Dilated pupils that are nonreactive to light
F Amnesia about the events around the time of injury
Verified Answer: A, C, F
NUR 265 Exam 3 Comprehensive
Practice Exam Questions & Verified
Answers Updated 2026 Just Released
Pass Guaranteed
This practice exam covers the key concepts for NUR 265 Exam 3
including traumatic brain injury, increased intracranial pressure,
meningitis, encephalitis, myasthenia gravis, Guillain-Barre
syndrome, spinal cord injury, autonomic dysreflexia, burns, and
sepsis. Each question is followed by the correct answer and a
detailed rationale explaining the clinical reasoning and nursing
priorities.
PART 1: TRAUMATIC BRAIN INJURY AND INCREASED
INTRACRANIAL PRESSURE
Question 1
The nurse is caring for an adult client who was recently admitted with a
head injury following a motor vehicle crash. One hour ago the clients
vital signs were temperature 98.6 degrees Fahrenheit pulse 110
,2 | Page
respirations 26 blood pressure 128 over 68 mm Hg. Which of the
following findings is a priority for the nurse to follow up
A Pulse 90 respirations 32 blood pressure 130 over 72 mm Hg
B Pulse 120 respirations 26 blood pressure 110 over 70 mm Hg
C Pulse 56 respirations 14 blood pressure 166 over 52 mm Hg
D Pulse 64 respirations 30 blood pressure 148 over 78 mm Hg
Verified Answer: C
Rationale: Cushing's triad of bradycardia, irregular respirations, and
widening pulse pressure with hypertension is a classic sign of increased
intracranial pressure. This is a medical emergency that requires
immediate intervention. The pulse of 56 and blood pressure of 166 over
52 with respirations of 14 indicate ICP elevation and potential brain
herniation.
Question 2
The nurse is caring for a client who sustained a closed head injury, is
receiving mechanical ventilation, and is at risk for developing increased
intracranial pressure. Which of the following actions should the nurse
take when caring for this client
A Perform passive range of motion to the clients hips and knees
B Log roll the client during turning and repositioning
C Elevate the foot of the clients bed
D Notify the charge nurse if the clients PaCO2 decreases from 39 to 35
mm Hg
,3 | Page
Verified Answer: B
Rationale: Log rolling maintains spinal alignment and prevents sudden
movements that could increase ICP. The head of the bed should be
elevated to 30 to 45 degrees to promote venous drainage. Hip flexion
should be avoided as it increases intra-abdominal pressure and ICP.
Question 3
The newly hired nurse is caring for a client who was admitted 12 hours
ago with a traumatic brain injury, is intubated, and is at risk for
developing increased intracranial pressure. Which interventions should
the nurse include in the clients plan of care
A Avoid clustering client care activities
B Maintain the head in a flexed position
C Provide a quiet environment by limiting visitors
D Have the client cough and deep breathe every hour
E Hyperoxygenate the client before and after suctioning
F Avoid maintaining hips in a flexed position
Verified Answer: A, C, E, F
Rationale: Interventions to reduce ICP include avoiding clustering care
activities to prevent stimulation, providing a quiet environment,
hyperoxygenating before and after suctioning, and avoiding hip flexion.
The head should be maintained in a neutral position not flexed.
Coughing increases ICP and should be avoided.
Question 4
, 4 | Page
The nurse working in the intensive care unit is assessing a client who
sustained a basilar skull fracture 24 hours ago. It is most important to
follow up with the primary health care provider if the client
A Becomes irritable and restless
B Has bruises under the eyes
C Is unable to name the state capital
D Reports having a persistent headache since admission
Verified Answer: A
Rationale: Irritability and restlessness may indicate increasing ICP or
neurological deterioration. Bruising under the eyes raccoon eyes is
expected with basilar skull fracture. A persistent headache is expected. A
change in level of consciousness or orientation is a priority finding.
Question 5
The nurse is assessing a client who has experienced a mild traumatic
brain injury. Which findings are consistent with this diagnosis
A Dizziness and gait problems
B A widened pulse pressure
C Increased sensitivity to light or noise
D A Glasgow Coma Scale score of 9
E Dilated pupils that are nonreactive to light
F Amnesia about the events around the time of injury
Verified Answer: A, C, F
