NUR 265 Actual Exam 3: Med- Surg 2026/2027
Questions and 100% Correct Answers– Galen
Overview:
NUR 265 Actual Exam 3: Med- Surg covers neurological emergencies including
traumatic brain injury, increased intracranial pressure, Cushing's Triad, basilar
skull fracture, concussion, craniotomy care, SIADH, bacterial meningitis, spinal
cord injury with neurogenic shock, myasthenia gravis, Guillain-Barré syndrome,
and ALS. Focuses on burn management using Rule of Nines, Parkland fluid
resuscitation, inhalation injury, carbon monoxide poisoning, and escharotomy.
Includes shock states, SIRS, sepsis, septic, hypovolemic, cardiogenic,
obstructive, and anaphylactic shock, vasopressors, and critical care nursing
priorities.
Correct answer highlighted in bold Green + rationales
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 client's vital signs (VS) were temperature
(T): 98.6° F; pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of
the following findings is a priority for the nurse to follow up?
A. P: 90; R: 32; BP: 130/72 mm Hg
B. P: 120; R: 26, BP: 110/70 mm Hg
C. P: 56; R: 14; BP: 166/52 mm Hg
D. P: 64, R: 30; BP: 148/78 mm Hg
Rationale: Cushing's Triad indicates increased ICP: bradycardia 56, decreased respirations 14,
widened pulse pressure with hypertension 166/52. Compared to baseline (P 110, BP 128/68),
this shows severe ICP elevation and impending herniation.
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 (ICP). Which of the
following actions should the nurse take when caring for this client?
A. Perform passive range of motion (ROM) to the client's hips and knees
,B. Log roll the client during turning and repositioning
C. Elevate the foot of the client's bed
D. Notify the charge nurse if the client's PaCO2 decreases from 39 to 35 mm Hg
Rationale: Log rolling prevents neck flexion and maintains alignment, preventing increased
ICP. Hip flexion, Trendelenburg, and hypocapnia below 35 can increase ICP. Maintain HOB 30
degrees, neutral head alignment.
3.) The newly hired nurse is caring for a client who was admitted 12 hours ago with a
traumatic brain injury (TBI), is intubated, and is at risk for developing increased intracranial
pressure (ICP). Which interventions from the box below should the nurse include in the
client's plan of care? 1 Avoid clustering client care activities. 2 Maintain the head in a flexed
position. 3 Provide a quiet environment by limiting visitors. 4 Have the client cough and deep
breathe every hour. 5 Hyperoxygenate the client before and after suctioning. 6 Avoid
maintaining hips in a flexed position.
A. 1, 3, 4, 5
B. 1, 3, 5, 6
C. 1, 2, 4, 6
D. 2, 4, 6
Rationale: To prevent ICP elevation: avoid clustering care, provide quiet environment,
hyperoxygenate before/after suctioning, avoid hip flexion and head flexion. Coughing and
flexed head increase ICP and should be avoided.
4.) The nurse working in the intensive care unit (ICU) 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 (PHCP) if the client
A. Becomes irritable and restless
B. Has bruises under the eyes (raccoon eyes)
C. Is unable to name the state capital
D. Reports having a persistent headache since admission
, Rationale: Irritability and restlessness are early signs of increasing ICP and neurological
deterioration. Raccoon eyes and Battle's sign are expected with basilar fracture; persistent
headache is common but restlessness indicates change in LOC.
5.) The nurse is assessing a client who has experienced a mild traumatic brain injury (TBI).
Which findings from the box below are consistent with this diagnosis? 1 Dizziness and gait
problems. 2 A widened pulse pressure. 3 Increased sensitivity to light or noise. 4 A Glasgow
Coma Scale (GCS) score of 9. 5 Dilated pupils that are nonreactive to light. 6 Amnesia about
the events around the time of injury.
A. 1, 3, 6
B. 3, 5, 6
C. 2, 3, 4, 5
D. 1, 2, 4, 6
Rationale: Mild TBI: dizziness, gait disturbance, photophobia/phonophobia, amnesia. GCS 13-
15 in mild TBI. Widened pulse pressure, GCS 9, and fixed dilated pupils indicate severe TBI and
increased ICP.
6.) The nurse is providing discharge instructions to the parents of a 15-year-old female who
sustained a concussion while playing field hockey. Which of the following statements by a
parent indicates a need for further teaching?
A. We should avoid giving any acetaminophen to treat headaches
B. We need to bring our daughter back to the emergency department if she exhibits blurred
vision
C. We should provide a consistent routine at home to assist with any behavior changes
D. We will not allow our daughter to engage in strenuous activity for at least 48 hours
Rationale: Acetaminophen is allowed for post-concussive headache; NSAIDs, aspirin, and
sedatives should be avoided. Blurred vision, behavior changes, and avoiding strenuous activity
are correct teachings. Avoiding all acetaminophen indicates need for further teaching.
7.) The nurse is assessing clients for the risk of sustaining a traumatic brain injury (TBI). Which
of the following clients should the nurse identify as being at greatest risk?
Questions and 100% Correct Answers– Galen
Overview:
NUR 265 Actual Exam 3: Med- Surg covers neurological emergencies including
traumatic brain injury, increased intracranial pressure, Cushing's Triad, basilar
skull fracture, concussion, craniotomy care, SIADH, bacterial meningitis, spinal
cord injury with neurogenic shock, myasthenia gravis, Guillain-Barré syndrome,
and ALS. Focuses on burn management using Rule of Nines, Parkland fluid
resuscitation, inhalation injury, carbon monoxide poisoning, and escharotomy.
Includes shock states, SIRS, sepsis, septic, hypovolemic, cardiogenic,
obstructive, and anaphylactic shock, vasopressors, and critical care nursing
priorities.
Correct answer highlighted in bold Green + rationales
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 client's vital signs (VS) were temperature
(T): 98.6° F; pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of
the following findings is a priority for the nurse to follow up?
A. P: 90; R: 32; BP: 130/72 mm Hg
B. P: 120; R: 26, BP: 110/70 mm Hg
C. P: 56; R: 14; BP: 166/52 mm Hg
D. P: 64, R: 30; BP: 148/78 mm Hg
Rationale: Cushing's Triad indicates increased ICP: bradycardia 56, decreased respirations 14,
widened pulse pressure with hypertension 166/52. Compared to baseline (P 110, BP 128/68),
this shows severe ICP elevation and impending herniation.
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 (ICP). Which of the
following actions should the nurse take when caring for this client?
A. Perform passive range of motion (ROM) to the client's hips and knees
,B. Log roll the client during turning and repositioning
C. Elevate the foot of the client's bed
D. Notify the charge nurse if the client's PaCO2 decreases from 39 to 35 mm Hg
Rationale: Log rolling prevents neck flexion and maintains alignment, preventing increased
ICP. Hip flexion, Trendelenburg, and hypocapnia below 35 can increase ICP. Maintain HOB 30
degrees, neutral head alignment.
3.) The newly hired nurse is caring for a client who was admitted 12 hours ago with a
traumatic brain injury (TBI), is intubated, and is at risk for developing increased intracranial
pressure (ICP). Which interventions from the box below should the nurse include in the
client's plan of care? 1 Avoid clustering client care activities. 2 Maintain the head in a flexed
position. 3 Provide a quiet environment by limiting visitors. 4 Have the client cough and deep
breathe every hour. 5 Hyperoxygenate the client before and after suctioning. 6 Avoid
maintaining hips in a flexed position.
A. 1, 3, 4, 5
B. 1, 3, 5, 6
C. 1, 2, 4, 6
D. 2, 4, 6
Rationale: To prevent ICP elevation: avoid clustering care, provide quiet environment,
hyperoxygenate before/after suctioning, avoid hip flexion and head flexion. Coughing and
flexed head increase ICP and should be avoided.
4.) The nurse working in the intensive care unit (ICU) 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 (PHCP) if the client
A. Becomes irritable and restless
B. Has bruises under the eyes (raccoon eyes)
C. Is unable to name the state capital
D. Reports having a persistent headache since admission
, Rationale: Irritability and restlessness are early signs of increasing ICP and neurological
deterioration. Raccoon eyes and Battle's sign are expected with basilar fracture; persistent
headache is common but restlessness indicates change in LOC.
5.) The nurse is assessing a client who has experienced a mild traumatic brain injury (TBI).
Which findings from the box below are consistent with this diagnosis? 1 Dizziness and gait
problems. 2 A widened pulse pressure. 3 Increased sensitivity to light or noise. 4 A Glasgow
Coma Scale (GCS) score of 9. 5 Dilated pupils that are nonreactive to light. 6 Amnesia about
the events around the time of injury.
A. 1, 3, 6
B. 3, 5, 6
C. 2, 3, 4, 5
D. 1, 2, 4, 6
Rationale: Mild TBI: dizziness, gait disturbance, photophobia/phonophobia, amnesia. GCS 13-
15 in mild TBI. Widened pulse pressure, GCS 9, and fixed dilated pupils indicate severe TBI and
increased ICP.
6.) The nurse is providing discharge instructions to the parents of a 15-year-old female who
sustained a concussion while playing field hockey. Which of the following statements by a
parent indicates a need for further teaching?
A. We should avoid giving any acetaminophen to treat headaches
B. We need to bring our daughter back to the emergency department if she exhibits blurred
vision
C. We should provide a consistent routine at home to assist with any behavior changes
D. We will not allow our daughter to engage in strenuous activity for at least 48 hours
Rationale: Acetaminophen is allowed for post-concussive headache; NSAIDs, aspirin, and
sedatives should be avoided. Blurred vision, behavior changes, and avoiding strenuous activity
are correct teachings. Avoiding all acetaminophen indicates need for further teaching.
7.) The nurse is assessing clients for the risk of sustaining a traumatic brain injury (TBI). Which
of the following clients should the nurse identify as being at greatest risk?
