NR 341 Exam 2 Practice Questions — 26–50
, NR 341 EXAM 2 – COMPLEX ADULT
HEALTH – (2026) ACTUAL QUESTIONS &
ANSWERS (CHAMBERLAIN) 100%
GUARANTEE PASS
26. A client with a severe head injury develops worsening headache, vomiting, and a decreasing
level of consciousness. Which intervention should the nurse prioritize?
A. Place the client flat
B. Elevate the head of the bed and maintain neutral neck alignment
C. Encourage coughing and deep breathing
D. Administer oral fluids
Correct Answer: B. Elevate the head of the bed and maintain neutral neck alignment
Rationale: Elevating the head and maintaining neutral alignment can promote venous drainage
from the brain and help reduce intracranial pressure (ICP). Avoid positions and activities that
increase ICP.
27. Which assessment finding is most concerning for increased intracranial pressure?
A. Mild headache
B. Blood pressure 118/72 mmHg
C. Decreasing level of consciousness
D. Temperature of 37°C
, Correct Answer: C. Decreasing level of consciousness
Rationale: A declining level of consciousness is an important early indicator of worsening
neurologic function and increased ICP.
28. A client with a traumatic brain injury develops hypertension, bradycardia, and irregular
respirations. What does the nurse suspect?
A. Hypovolemic shock
B. Cushing response
C. Neurogenic shock
D. Pulmonary embolism
Correct Answer: B. Cushing response
Rationale: The combination of increasing systolic blood pressure/widened pulse pressure,
bradycardia, and irregular respirations is associated with significantly increased ICP.
29. A client has clear drainage coming from the nose following a head injury. Which action is
appropriate?
A. Insert a nasal airway
B. Pack the nose tightly
C. Assess the drainage for possible cerebrospinal fluid
D. Encourage the client to blow the nose
Correct Answer: C. Assess the drainage for possible cerebrospinal fluid
, Rationale: Clear drainage after head trauma may indicate a CSF leak associated with a basilar
skull fracture. Nasal instrumentation and nose blowing should be avoided.
30. Which finding is most characteristic of an epidural hematoma?
A. Gradual neurologic deterioration over several days
B. Loss of consciousness followed by a possible lucid interval
C. Severe hypertension and bradycardia immediately
D. Bilateral lower-extremity paralysis
Correct Answer: B. Loss of consciousness followed by a possible lucid interval
Rationale: Epidural hematomas are often associated with arterial bleeding and may present
with an initial loss of consciousness followed by a temporary period of apparent improvement
before deterioration.
31. A client develops a sudden, severe headache described as the “worst headache of my life.”
Which condition should the nurse suspect?
A. Subarachnoid hemorrhage
B. Tension headache
C. Migraine only
D. Sinusitis
Correct Answer: A. Subarachnoid hemorrhage
, NR 341 EXAM 2 – COMPLEX ADULT
HEALTH – (2026) ACTUAL QUESTIONS &
ANSWERS (CHAMBERLAIN) 100%
GUARANTEE PASS
26. A client with a severe head injury develops worsening headache, vomiting, and a decreasing
level of consciousness. Which intervention should the nurse prioritize?
A. Place the client flat
B. Elevate the head of the bed and maintain neutral neck alignment
C. Encourage coughing and deep breathing
D. Administer oral fluids
Correct Answer: B. Elevate the head of the bed and maintain neutral neck alignment
Rationale: Elevating the head and maintaining neutral alignment can promote venous drainage
from the brain and help reduce intracranial pressure (ICP). Avoid positions and activities that
increase ICP.
27. Which assessment finding is most concerning for increased intracranial pressure?
A. Mild headache
B. Blood pressure 118/72 mmHg
C. Decreasing level of consciousness
D. Temperature of 37°C
, Correct Answer: C. Decreasing level of consciousness
Rationale: A declining level of consciousness is an important early indicator of worsening
neurologic function and increased ICP.
28. A client with a traumatic brain injury develops hypertension, bradycardia, and irregular
respirations. What does the nurse suspect?
A. Hypovolemic shock
B. Cushing response
C. Neurogenic shock
D. Pulmonary embolism
Correct Answer: B. Cushing response
Rationale: The combination of increasing systolic blood pressure/widened pulse pressure,
bradycardia, and irregular respirations is associated with significantly increased ICP.
29. A client has clear drainage coming from the nose following a head injury. Which action is
appropriate?
A. Insert a nasal airway
B. Pack the nose tightly
C. Assess the drainage for possible cerebrospinal fluid
D. Encourage the client to blow the nose
Correct Answer: C. Assess the drainage for possible cerebrospinal fluid
, Rationale: Clear drainage after head trauma may indicate a CSF leak associated with a basilar
skull fracture. Nasal instrumentation and nose blowing should be avoided.
30. Which finding is most characteristic of an epidural hematoma?
A. Gradual neurologic deterioration over several days
B. Loss of consciousness followed by a possible lucid interval
C. Severe hypertension and bradycardia immediately
D. Bilateral lower-extremity paralysis
Correct Answer: B. Loss of consciousness followed by a possible lucid interval
Rationale: Epidural hematomas are often associated with arterial bleeding and may present
with an initial loss of consciousness followed by a temporary period of apparent improvement
before deterioration.
31. A client develops a sudden, severe headache described as the “worst headache of my life.”
Which condition should the nurse suspect?
A. Subarachnoid hemorrhage
B. Tension headache
C. Migraine only
D. Sinusitis
Correct Answer: A. Subarachnoid hemorrhage
