,NUR 2755 Exam 1 | Multidimensional Care IV (2026) Actual Q&A
PDF | Rasmussen College
1. The nurse is assessing a patient with a traumatic brain injury. Which finding is the most
sensitive early indicator of neurological decline?
A) Decerebrate posturing
B) A decrease in level of consciousness (LOC) from alert to lethargic
C) A new unilateral fixed and dilated pupil
D) Development of Cushing's triad
Correct Answer: A decrease in level of consciousness (LOC) from alert to lethargic
Rationale: LOC is the earliest and most sensitive indicator of changes in neurological status.
Subtle shifts, such as progressing from alert to lethargic, often precede pupillary changes or
vital sign abnormalities. Cushing's triad and posturing are late, ominous signs. Frequent
monitoring of LOC allows early intervention.
2. A patient with a traumatic brain injury is being monitored for increased intracranial
pressure (ICP). Which assessment finding constitutes Cushing's triad?
A) Hypotension, tachycardia, and tachypnea
B) Bradycardia, hypertension with widening pulse pressure, and irregular respirations
C) Fever, neck stiffness, and photophobia
D) Unilateral weakness, facial droop, and aphasia
Correct Answer: Bradycardia, hypertension with widening pulse pressure, and irregular
respirations
Rationale: Cushing's triad reflects the brain's response to severe intracranial hypertension
and consists of bradycardia, systolic hypertension with a widened pulse pressure, and
irregular respirations. This is a late, life-threatening sign that requires immediate
intervention.
,3. Which lobe of the brain is primarily responsible for expressive speech and motor
function?
A) Frontal lobe
B) Temporal lobe
C) Parietal lobe
D) Occipital lobe
Correct Answer: Frontal lobe
Rationale: The frontal lobe contains Broca's area, which is responsible for expressive speech.
It also houses the primary motor cortex. A stroke or injury in this area can result in
expressive aphasia and contralateral motor deficits.
4. The nurse is assessing a patient with a left frontal lobe stroke. Which deficit is most likely?
A) Left-sided neglect
B) Visual hallucinations
C) Expressive aphasia and right-sided weakness
D) Receptive aphasia
Correct Answer: Expressive aphasia and right-sided weakness
Rationale: The left frontal lobe contains Broca's area (expressive speech). A stroke here
causes contralateral motor deficits (right-sided weakness). Left neglect is typically associated
with right parietal lobe damage, and receptive aphasia is associated with Wernicke's area in
the temporal lobe.
5. A patient with a seizure disorder asks the nurse about potential triggers. Which trigger
should the nurse instruct the patient to avoid?
A) Aerobic exercise
B) Stress, fatigue, and flashing lights
C) A high-fiber diet
D) A regular sleep schedule
, Correct Answer: Stress, fatigue, and flashing lights
Rationale: Common seizure triggers include stress, fatigue, sleep deprivation, and flashing or
strobe lights. A regular sleep schedule, a balanced diet, and exercise are generally
encouraged to promote overall health and seizure control.
6. The nurse is providing safety education to the family of a client with moderate Alzheimer's
disease. Which instruction is most important?
A) "Encourage the client to drive independently to maintain autonomy."
B) "Remove throw rugs and dangerous objects from the environment."
C) "Keep the environment unstructured to promote flexibility."
D) "Allow the client to use the stairs for exercise."
Correct Answer: "Remove throw rugs and dangerous objects from the environment."
Rationale: Safety is the priority for clients with Alzheimer's disease. Removing throw rugs
and other tripping hazards reduces the risk of falls and injury. A structured environment with
supervision is recommended to maintain safety.
7. A client with Alzheimer's disease is in the moderate stage. Which finding is most
consistent with this stage?
A) Complete dependence on activities of daily living (ADLs) and loss of verbal skills
B) Disorientation to time, place, and event with difficulty handling finances
C) Forgetting names and misplacing household objects
D) Loss of mobility and development of tremors
Correct Answer: Disorientation to time, place, and event with difficulty handling finances
Rationale: In the moderate stage of Alzheimer's disease, clients demonstrate disorientation
to time, place, and events, along with difficulty handling money or finances. The mild stage
includes forgetting names, and the severe stage includes complete ADL dependence.
PDF | Rasmussen College
1. The nurse is assessing a patient with a traumatic brain injury. Which finding is the most
sensitive early indicator of neurological decline?
A) Decerebrate posturing
B) A decrease in level of consciousness (LOC) from alert to lethargic
C) A new unilateral fixed and dilated pupil
D) Development of Cushing's triad
Correct Answer: A decrease in level of consciousness (LOC) from alert to lethargic
Rationale: LOC is the earliest and most sensitive indicator of changes in neurological status.
Subtle shifts, such as progressing from alert to lethargic, often precede pupillary changes or
vital sign abnormalities. Cushing's triad and posturing are late, ominous signs. Frequent
monitoring of LOC allows early intervention.
2. A patient with a traumatic brain injury is being monitored for increased intracranial
pressure (ICP). Which assessment finding constitutes Cushing's triad?
A) Hypotension, tachycardia, and tachypnea
B) Bradycardia, hypertension with widening pulse pressure, and irregular respirations
C) Fever, neck stiffness, and photophobia
D) Unilateral weakness, facial droop, and aphasia
Correct Answer: Bradycardia, hypertension with widening pulse pressure, and irregular
respirations
Rationale: Cushing's triad reflects the brain's response to severe intracranial hypertension
and consists of bradycardia, systolic hypertension with a widened pulse pressure, and
irregular respirations. This is a late, life-threatening sign that requires immediate
intervention.
,3. Which lobe of the brain is primarily responsible for expressive speech and motor
function?
A) Frontal lobe
B) Temporal lobe
C) Parietal lobe
D) Occipital lobe
Correct Answer: Frontal lobe
Rationale: The frontal lobe contains Broca's area, which is responsible for expressive speech.
It also houses the primary motor cortex. A stroke or injury in this area can result in
expressive aphasia and contralateral motor deficits.
4. The nurse is assessing a patient with a left frontal lobe stroke. Which deficit is most likely?
A) Left-sided neglect
B) Visual hallucinations
C) Expressive aphasia and right-sided weakness
D) Receptive aphasia
Correct Answer: Expressive aphasia and right-sided weakness
Rationale: The left frontal lobe contains Broca's area (expressive speech). A stroke here
causes contralateral motor deficits (right-sided weakness). Left neglect is typically associated
with right parietal lobe damage, and receptive aphasia is associated with Wernicke's area in
the temporal lobe.
5. A patient with a seizure disorder asks the nurse about potential triggers. Which trigger
should the nurse instruct the patient to avoid?
A) Aerobic exercise
B) Stress, fatigue, and flashing lights
C) A high-fiber diet
D) A regular sleep schedule
, Correct Answer: Stress, fatigue, and flashing lights
Rationale: Common seizure triggers include stress, fatigue, sleep deprivation, and flashing or
strobe lights. A regular sleep schedule, a balanced diet, and exercise are generally
encouraged to promote overall health and seizure control.
6. The nurse is providing safety education to the family of a client with moderate Alzheimer's
disease. Which instruction is most important?
A) "Encourage the client to drive independently to maintain autonomy."
B) "Remove throw rugs and dangerous objects from the environment."
C) "Keep the environment unstructured to promote flexibility."
D) "Allow the client to use the stairs for exercise."
Correct Answer: "Remove throw rugs and dangerous objects from the environment."
Rationale: Safety is the priority for clients with Alzheimer's disease. Removing throw rugs
and other tripping hazards reduces the risk of falls and injury. A structured environment with
supervision is recommended to maintain safety.
7. A client with Alzheimer's disease is in the moderate stage. Which finding is most
consistent with this stage?
A) Complete dependence on activities of daily living (ADLs) and loss of verbal skills
B) Disorientation to time, place, and event with difficulty handling finances
C) Forgetting names and misplacing household objects
D) Loss of mobility and development of tremors
Correct Answer: Disorientation to time, place, and event with difficulty handling finances
Rationale: In the moderate stage of Alzheimer's disease, clients demonstrate disorientation
to time, place, and events, along with difficulty handling money or finances. The mild stage
includes forgetting names, and the severe stage includes complete ADL dependence.
