,ASU NUR 425 Final Exam | Health and Illness Concepts:
Adults and Pediatrics (2026) Q&A
1. A nurse is assessing a patient with suspected increased intracranial pressure (ICP).
Which assessment finding is the earliest indicator of a change in neurological status?
A) Change in level of consciousness
B) Pupillary changes
C) Cushing's triad
D) Motor deficits
Correct Answer: Change in level of consciousness
Rationale: A change in level of consciousness (LOC) is the earliest and most sensitive
indicator of increasing ICP. As pressure rises, cerebral perfusion decreases, affecting
the reticular activating system, which produces drowsiness, confusion, and lethargy.
Pupillary changes, Cushing's triad, and motor deficits are later signs.
2. A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 60
mmHg and an intracranial pressure (ICP) of 20 mmHg. What is the cerebral perfusion
pressure (CPP)?
A) 20 mmHg
B) 40 mmHg
C) 60 mmHg
D) 80 mmHg
Correct Answer: 40 mmHg
,Rationale: Cerebral perfusion pressure is calculated as MAP minus ICP. This patient's
CPP = 60 - 20 = 40 mmHg. Normal CPP in adults is 60-100 mmHg; in children, it is
40-60 mmHg. A CPP below 50 mmHg is associated with cerebral ischemia and poor
outcomes.
3. A child with bacterial meningitis is admitted to the pediatric intensive care unit.
Which assessment finding is most concerning and requires immediate intervention?
A) Positive Kernig's sign
B) Nuchal rigidity
C) Bulging fontanel
D) Fever of 39°C
Correct Answer: Bulging fontanel
Rationale: A bulging fontanel in an infant is a sign of increased intracranial pressure,
which requires immediate intervention to prevent brain herniation. Kernig's sign,
nuchal rigidity, and fever are also signs of meningitis, but a bulging fontanel
indicates a more urgent neurological compromise.
4. A nurse is caring for a patient with a chest tube. Which finding indicates an air
leak?
A) Tidaling in the water seal chamber
B) Continuous bubbling in the water seal chamber
C) Absence of bubbling in the suction control chamber
D) Serosanguinous drainage in the collection chamber
Correct Answer: Continuous bubbling in the water seal chamber
, Rationale: Continuous bubbling in the water seal chamber indicates an air leak in
the chest tube system. The nurse should check for loose connections, cracks, or
dislodgement. Tidaling is normal and reflects respiratory variation. The suction
control chamber should have gentle bubbling.
5. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen
at 2 L/min via nasal cannula. The oxygen saturation is 91%. What is the most
appropriate action?
A) Increase the oxygen to 4 L/min
B) Maintain the current oxygen flow rate
C) Decrease the oxygen to 1 L/min
D) Discontinue the oxygen
Correct Answer: Maintain the current oxygen flow rate
Rationale: For most COPD patients, the target oxygen saturation is 88-92% to avoid
suppressing the hypoxic drive. A saturation of 91% is within the target range, so the
current flow rate should be maintained. Increasing the oxygen could lead to CO₂
retention.
6. A nurse is preparing to administer a blood transfusion to a patient with a history of
heart failure. Which complication is the patient at highest risk for?
A) Hyperkalemia
B) Fluid overload
C) Hypoglycemia
D) Hyponatremia
Correct Answer: Fluid overload
Adults and Pediatrics (2026) Q&A
1. A nurse is assessing a patient with suspected increased intracranial pressure (ICP).
Which assessment finding is the earliest indicator of a change in neurological status?
A) Change in level of consciousness
B) Pupillary changes
C) Cushing's triad
D) Motor deficits
Correct Answer: Change in level of consciousness
Rationale: A change in level of consciousness (LOC) is the earliest and most sensitive
indicator of increasing ICP. As pressure rises, cerebral perfusion decreases, affecting
the reticular activating system, which produces drowsiness, confusion, and lethargy.
Pupillary changes, Cushing's triad, and motor deficits are later signs.
2. A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 60
mmHg and an intracranial pressure (ICP) of 20 mmHg. What is the cerebral perfusion
pressure (CPP)?
A) 20 mmHg
B) 40 mmHg
C) 60 mmHg
D) 80 mmHg
Correct Answer: 40 mmHg
,Rationale: Cerebral perfusion pressure is calculated as MAP minus ICP. This patient's
CPP = 60 - 20 = 40 mmHg. Normal CPP in adults is 60-100 mmHg; in children, it is
40-60 mmHg. A CPP below 50 mmHg is associated with cerebral ischemia and poor
outcomes.
3. A child with bacterial meningitis is admitted to the pediatric intensive care unit.
Which assessment finding is most concerning and requires immediate intervention?
A) Positive Kernig's sign
B) Nuchal rigidity
C) Bulging fontanel
D) Fever of 39°C
Correct Answer: Bulging fontanel
Rationale: A bulging fontanel in an infant is a sign of increased intracranial pressure,
which requires immediate intervention to prevent brain herniation. Kernig's sign,
nuchal rigidity, and fever are also signs of meningitis, but a bulging fontanel
indicates a more urgent neurological compromise.
4. A nurse is caring for a patient with a chest tube. Which finding indicates an air
leak?
A) Tidaling in the water seal chamber
B) Continuous bubbling in the water seal chamber
C) Absence of bubbling in the suction control chamber
D) Serosanguinous drainage in the collection chamber
Correct Answer: Continuous bubbling in the water seal chamber
, Rationale: Continuous bubbling in the water seal chamber indicates an air leak in
the chest tube system. The nurse should check for loose connections, cracks, or
dislodgement. Tidaling is normal and reflects respiratory variation. The suction
control chamber should have gentle bubbling.
5. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen
at 2 L/min via nasal cannula. The oxygen saturation is 91%. What is the most
appropriate action?
A) Increase the oxygen to 4 L/min
B) Maintain the current oxygen flow rate
C) Decrease the oxygen to 1 L/min
D) Discontinue the oxygen
Correct Answer: Maintain the current oxygen flow rate
Rationale: For most COPD patients, the target oxygen saturation is 88-92% to avoid
suppressing the hypoxic drive. A saturation of 91% is within the target range, so the
current flow rate should be maintained. Increasing the oxygen could lead to CO₂
retention.
6. A nurse is preparing to administer a blood transfusion to a patient with a history of
heart failure. Which complication is the patient at highest risk for?
A) Hyperkalemia
B) Fluid overload
C) Hypoglycemia
D) Hyponatremia
Correct Answer: Fluid overload
