NURS 424 EXAM 3 BLUEPRINT | 2026
UPDATED | WITH COMPLETE SOLUTIONS.
A patient with a traumatic brain injury has an intracranial pressure (ICP)
of 22 mmHg and a mean arterial pressure (MAP) of 90 mmHg. What is
the patient's cerebral perfusion pressure (CPP) and what is the clinical
significance of this finding?
A) CPP is 68 mmHg, which is adequate for cerebral perfusion
B) CPP is 112 mmHg, which indicates hyperemia and increased bleeding
risk
C) CPP is 62 mmHg, which is below the minimum threshold and indicates
inadequate cerebral perfusion
D) CPP is 90 mmHg, which is within normal limits
Answer: A) CPP is 68 mmHg, which is adequate for cerebral perfusion
Rationale: CPP = MAP - ICP. Therefore, 90 - 22 = 68 mmHg. A CPP
greater than 60 mmHg is required to maintain adequate brain perfusion.
While the ICP is elevated (normal is 5-15 mmHg), the CPP remains
adequate.
, A patient with increased intracranial pressure exhibits extension of all
extremities with internal rotation and plantar flexion. The nurse
documents this as which type of posturing, and what does it indicate
about the location of the injury?
A) Decorticate posturing, indicating injury above the brainstem
B) Decerebrate posturing, indicating injury at the brainstem level
C) Decorticate posturing, indicating injury at the brainstem level
D) Decerebrate posturing, indicating injury above the brainstem
Answer: B) Decerebrate posturing, indicating injury at the brainstem
level
Rationale: Decerebrate posturing is characterized by extension of all
extremities with internal rotation. It indicates injury at the brainstem
level and is associated with a poorer prognosis than decorticate
posturing.
A patient is admitted with a basilar skull fracture. Which assessment
findings are classic indicators of this injury and represent a medical
emergency?
A) Periorbital ecchymosis (raccoon eyes) and mastoid ecchymosis
(Battle's sign)
, B) Flaccid paralysis and loss of deep tendon reflexes
C) Decorticate posturing and anisocoria
D) Tachycardia and hypertension
Answer: A) Periorbital ecchymosis (raccoon eyes) and mastoid
ecchymosis (Battle's sign)
Rationale: Raccoon eyes and Battle's sign are classic signs of a basilar
skull fracture. This is a medical emergency because it indicates a CSF leak,
which significantly increases the risk of meningitis and altered ICP.
A patient has an ICP monitoring device in place. What is the nurse's
priority nursing intervention to prevent a serious complication?
A) Maintain strict aseptic technique during dressing changes to prevent
infection
B) Zero the transducer every 12 hours to ensure accuracy
C) Keep the head of the bed flat to promote cerebral perfusion
D) Flush the system with heparinized saline every hour
Answer: A) Maintain strict aseptic technique during dressing changes to
prevent infection
Rationale: Infection is the number one complication associated with
, invasive ICP monitoring devices. Strict aseptic technique during insertion
and maintenance is the priority intervention.
A patient with increased ICP is prescribed mannitol. The nurse should
monitor for which potential complication associated with this medication?
A) Hyponatremia and fluid overload
B) Hypernatremia and hypotension
C) Hypokalemia and bradycardia
D) Hyperglycemia and polyuria
Answer: B) Hypernatremia and hypotension
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the brain
into the vascular space and then promotes diuresis. This can lead to
significant fluid loss, resulting in hypernatremia and hypotension,
especially in patients with compromised cardiovascular status.
A patient is brought to the emergency department after a motor vehicle
accident. Which nursing action is the highest priority immediately upon
arrival?
A) Assess Glasgow Coma Scale (GCS) score
UPDATED | WITH COMPLETE SOLUTIONS.
A patient with a traumatic brain injury has an intracranial pressure (ICP)
of 22 mmHg and a mean arterial pressure (MAP) of 90 mmHg. What is
the patient's cerebral perfusion pressure (CPP) and what is the clinical
significance of this finding?
A) CPP is 68 mmHg, which is adequate for cerebral perfusion
B) CPP is 112 mmHg, which indicates hyperemia and increased bleeding
risk
C) CPP is 62 mmHg, which is below the minimum threshold and indicates
inadequate cerebral perfusion
D) CPP is 90 mmHg, which is within normal limits
Answer: A) CPP is 68 mmHg, which is adequate for cerebral perfusion
Rationale: CPP = MAP - ICP. Therefore, 90 - 22 = 68 mmHg. A CPP
greater than 60 mmHg is required to maintain adequate brain perfusion.
While the ICP is elevated (normal is 5-15 mmHg), the CPP remains
adequate.
, A patient with increased intracranial pressure exhibits extension of all
extremities with internal rotation and plantar flexion. The nurse
documents this as which type of posturing, and what does it indicate
about the location of the injury?
A) Decorticate posturing, indicating injury above the brainstem
B) Decerebrate posturing, indicating injury at the brainstem level
C) Decorticate posturing, indicating injury at the brainstem level
D) Decerebrate posturing, indicating injury above the brainstem
Answer: B) Decerebrate posturing, indicating injury at the brainstem
level
Rationale: Decerebrate posturing is characterized by extension of all
extremities with internal rotation. It indicates injury at the brainstem
level and is associated with a poorer prognosis than decorticate
posturing.
A patient is admitted with a basilar skull fracture. Which assessment
findings are classic indicators of this injury and represent a medical
emergency?
A) Periorbital ecchymosis (raccoon eyes) and mastoid ecchymosis
(Battle's sign)
, B) Flaccid paralysis and loss of deep tendon reflexes
C) Decorticate posturing and anisocoria
D) Tachycardia and hypertension
Answer: A) Periorbital ecchymosis (raccoon eyes) and mastoid
ecchymosis (Battle's sign)
Rationale: Raccoon eyes and Battle's sign are classic signs of a basilar
skull fracture. This is a medical emergency because it indicates a CSF leak,
which significantly increases the risk of meningitis and altered ICP.
A patient has an ICP monitoring device in place. What is the nurse's
priority nursing intervention to prevent a serious complication?
A) Maintain strict aseptic technique during dressing changes to prevent
infection
B) Zero the transducer every 12 hours to ensure accuracy
C) Keep the head of the bed flat to promote cerebral perfusion
D) Flush the system with heparinized saline every hour
Answer: A) Maintain strict aseptic technique during dressing changes to
prevent infection
Rationale: Infection is the number one complication associated with
, invasive ICP monitoring devices. Strict aseptic technique during insertion
and maintenance is the priority intervention.
A patient with increased ICP is prescribed mannitol. The nurse should
monitor for which potential complication associated with this medication?
A) Hyponatremia and fluid overload
B) Hypernatremia and hypotension
C) Hypokalemia and bradycardia
D) Hyperglycemia and polyuria
Answer: B) Hypernatremia and hypotension
Rationale: Mannitol is an osmotic diuretic that pulls fluid from the brain
into the vascular space and then promotes diuresis. This can lead to
significant fluid loss, resulting in hypernatremia and hypotension,
especially in patients with compromised cardiovascular status.
A patient is brought to the emergency department after a motor vehicle
accident. Which nursing action is the highest priority immediately upon
arrival?
A) Assess Glasgow Coma Scale (GCS) score
