,NUR 2755 Exam 3 | Multidimensional Care IV (2026) Actual Q&A
PDF | Rasmussen College
1. A patient presents with a sudden, severe headache described as "the worst headache of
my life." This is a classic sign of which condition?
A) Tension headache
B) Migraine with aura
C) Subarachnoid hemorrhage
D) Cluster headache
Correct Answer: Subarachnoid hemorrhage
Rationale: A sudden, severe headache described as "the worst headache of my life" is the
hallmark symptom of a subarachnoid hemorrhage (SAH) and often indicates a ruptured
cerebral aneurysm. Tension and cluster headaches typically do not present with this severity,
and migraines with aura usually have a more gradual onset.
2. A patient with a right-hemisphere stroke would most likely exhibit which finding?
A) Aphasia and right-sided weakness
B) Left-sided neglect, impulsivity, and left-sided weakness
C) Bilateral lower extremity paralysis
D) Ataxia and dysmetria
Correct Answer: Left-sided neglect, impulsivity, and left-sided weakness
Rationale: Right-hemisphere strokes commonly cause left-sided neglect (ignoring the left
side of the body or environment), impulsivity, and left-sided hemiparesis or hemiplegia.
Aphasia is more typical of left-hemisphere strokes.
3. Which finding is most concerning in a patient with a basilar skull fracture?
A) Periorbital ecchymosis (raccoon eyes)
,B) Mastoid ecchymosis (Battle's sign)
C) Clear nasal drainage positive for glucose
D) All of the above
Correct Answer: All of the above
Rationale: Raccoon eyes, Battle's sign, and clear nasal or otorrhea positive for glucose are all
signs of a basilar skull fracture and indicate a cerebrospinal fluid (CSF) leak. These findings
require immediate intervention to prevent infection.
4. A patient with increased intracranial pressure (ICP) has a Glasgow Coma Scale (GCS) score
of 8. What is the nurse's priority intervention?
A) Perform a neurological assessment every 4 hours
B) Elevate the head of the bed to 30 degrees
C) Administer prescribed pain medication
D) Provide oral care
Correct Answer: Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the
brain, reducing ICP. A GCS of 8 indicates severe neurological impairment requiring
immediate interventions.
5. A patient with increased ICP has a sudden drop in blood pressure and bradycardia. This
finding is most consistent with:
A) Cushing's triad
B) Hypovolemic shock
C) Septic shock
D) Brainstem compression
Correct Answer: Brainstem compression
, Rationale: Hypotension with bradycardia in a patient with ICP suggests brainstem
compression and is a late sign requiring emergency intervention. Cushing's triad consists of
hypertension, bradycardia, and irregular respirations.
6. Which medication is most likely to be prescribed to reduce cerebral edema in a patient
with increased ICP?
A) Furosemide
B) Mannitol
C) Hydrochlorothiazide
D) Spironolactone
Correct Answer: Mannitol
Rationale: Mannitol is an osmotic diuretic that reduces cerebral edema by drawing fluid
from the brain tissue into the vascular space. It is commonly used in the management of
increased ICP.
7. A patient with a subarachnoid hemorrhage is at risk for cerebral vasospasm. What should
the nurse monitor for?
A) Increased blood pressure
B) Decreased level of consciousness and focal neurologic deficits
C) Respiratory distress
D) Hyperthermia
Correct Answer: Decreased level of consciousness and focal neurologic deficits
Rationale: Cerebral vasospasm can cause delayed cerebral ischemia, leading to a decreased
level of consciousness and focal neurologic deficits. Early recognition is critical for prompt
intervention.
8. The nurse is assessing a patient with a suspected stroke. Which diagnostic test is most
important to distinguish between ischemic and hemorrhagic stroke?
A) Non-contrast CT scan of the head
PDF | Rasmussen College
1. A patient presents with a sudden, severe headache described as "the worst headache of
my life." This is a classic sign of which condition?
A) Tension headache
B) Migraine with aura
C) Subarachnoid hemorrhage
D) Cluster headache
Correct Answer: Subarachnoid hemorrhage
Rationale: A sudden, severe headache described as "the worst headache of my life" is the
hallmark symptom of a subarachnoid hemorrhage (SAH) and often indicates a ruptured
cerebral aneurysm. Tension and cluster headaches typically do not present with this severity,
and migraines with aura usually have a more gradual onset.
2. A patient with a right-hemisphere stroke would most likely exhibit which finding?
A) Aphasia and right-sided weakness
B) Left-sided neglect, impulsivity, and left-sided weakness
C) Bilateral lower extremity paralysis
D) Ataxia and dysmetria
Correct Answer: Left-sided neglect, impulsivity, and left-sided weakness
Rationale: Right-hemisphere strokes commonly cause left-sided neglect (ignoring the left
side of the body or environment), impulsivity, and left-sided hemiparesis or hemiplegia.
Aphasia is more typical of left-hemisphere strokes.
3. Which finding is most concerning in a patient with a basilar skull fracture?
A) Periorbital ecchymosis (raccoon eyes)
,B) Mastoid ecchymosis (Battle's sign)
C) Clear nasal drainage positive for glucose
D) All of the above
Correct Answer: All of the above
Rationale: Raccoon eyes, Battle's sign, and clear nasal or otorrhea positive for glucose are all
signs of a basilar skull fracture and indicate a cerebrospinal fluid (CSF) leak. These findings
require immediate intervention to prevent infection.
4. A patient with increased intracranial pressure (ICP) has a Glasgow Coma Scale (GCS) score
of 8. What is the nurse's priority intervention?
A) Perform a neurological assessment every 4 hours
B) Elevate the head of the bed to 30 degrees
C) Administer prescribed pain medication
D) Provide oral care
Correct Answer: Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the
brain, reducing ICP. A GCS of 8 indicates severe neurological impairment requiring
immediate interventions.
5. A patient with increased ICP has a sudden drop in blood pressure and bradycardia. This
finding is most consistent with:
A) Cushing's triad
B) Hypovolemic shock
C) Septic shock
D) Brainstem compression
Correct Answer: Brainstem compression
, Rationale: Hypotension with bradycardia in a patient with ICP suggests brainstem
compression and is a late sign requiring emergency intervention. Cushing's triad consists of
hypertension, bradycardia, and irregular respirations.
6. Which medication is most likely to be prescribed to reduce cerebral edema in a patient
with increased ICP?
A) Furosemide
B) Mannitol
C) Hydrochlorothiazide
D) Spironolactone
Correct Answer: Mannitol
Rationale: Mannitol is an osmotic diuretic that reduces cerebral edema by drawing fluid
from the brain tissue into the vascular space. It is commonly used in the management of
increased ICP.
7. A patient with a subarachnoid hemorrhage is at risk for cerebral vasospasm. What should
the nurse monitor for?
A) Increased blood pressure
B) Decreased level of consciousness and focal neurologic deficits
C) Respiratory distress
D) Hyperthermia
Correct Answer: Decreased level of consciousness and focal neurologic deficits
Rationale: Cerebral vasospasm can cause delayed cerebral ischemia, leading to a decreased
level of consciousness and focal neurologic deficits. Early recognition is critical for prompt
intervention.
8. The nurse is assessing a patient with a suspected stroke. Which diagnostic test is most
important to distinguish between ischemic and hemorrhagic stroke?
A) Non-contrast CT scan of the head
