,NUR 242 Exam 4 Test Bank | Medical-Surgical
Nursing | Galen College of Nursing | 2026/2027
Q&A Exam Prep PDF
1. A client with a traumatic brain injury becomes increasingly restless, has a headache, and the
nurse notes unequal pupils and a blood pressure of 180/60 mm Hg. What is the priority action?
A) Reorient the client and dim the lights
B) Administer prescribed PRN opioid analgesic
C) Elevate the head of the bed 30 degrees and notify the provider
D) Instruct the client to take slow, deep breaths
Correct Answer: C) Elevate the head of the bed 30 degrees and notify the provider
Rationale: Restlessness, headache, anisocoria (unequal pupils), and widened pulse pressure
indicate rising intracranial pressure (ICP). Elevating the head of the bed to 30° promotes venous
drainage from the brain and helps decrease ICP. The provider must be notified immediately.
Opioids can mask neurologic changes, and other options do not address the life-threatening ICP.
2. A client with increased intracranial pressure (ICP) is receiving mechanical ventilation. Which
ventilator setting change should the nurse question?
A) Increasing the respiratory rate to lower PaCO₂
B) Increasing positive end-expiratory pressure (PEEP)
C) Maintaining FiO₂ at 40%
D) Keeping tidal volume within normal range
,Correct Answer: B) Increasing positive end-expiratory pressure (PEEP)
Rationale: High PEEP increases intrathoracic pressure, which can reduce venous return from the
brain and worsen ICP. Mild hyperventilation (lower PaCO₂) causes cerebral vasoconstriction and
can help lower ICP short term, and normal tidal volume and FiO₂ are not problematic.
3. The nurse is assessing a client with a head injury. Which finding is the earliest indicator of
increased intracranial pressure?
A) Cushing's triad
B) Change in level of consciousness
C) Pupillary changes
D) Motor posturing
Correct Answer: B) Change in level of consciousness
Rationale: A change in level of consciousness (LOC) is the earliest and most reliable indicator of
increased ICP. Cushing's triad, pupillary changes, and motor posturing are later signs.
4. A client with increased ICP exhibits a blood pressure of 180/100 mmHg, heart rate of 52 bpm,
and irregular respirations. The nurse should recognize this as:
A) Normal vital signs
B) Cushing's triad
C) Signs of shock
D) Side effects of medication
, Correct Answer: B) Cushing's triad
Rationale: Cushing's triad (hypertension, bradycardia, and irregular respirations) is a late sign of
increased ICP and indicates impending herniation, requiring immediate intervention.
5. A client is experiencing a generalized tonic-clonic seizure. Which nursing action is most
appropriate?
A) Restrain the client to prevent injury
B) Place a tongue blade in the client's mouth
C) Protect the client's head and turn them to the side
D) Administer oral medications
Correct Answer: C) Protect the client's head and turn them to the side
Rationale: During a seizure, the nurse should protect the client's head and turn them to the side
to prevent aspiration. Restraints should never be used during a seizure, and nothing should be
placed in the client's mouth. Oral medications should not be given during a seizure.
6. A client is in the postictal phase after a seizure. Which assessment finding is most consistent
with this phase?
A) Hyperactivity and agitation
B) Confusion and drowsiness
C) Immediate return to baseline mental status
Nursing | Galen College of Nursing | 2026/2027
Q&A Exam Prep PDF
1. A client with a traumatic brain injury becomes increasingly restless, has a headache, and the
nurse notes unequal pupils and a blood pressure of 180/60 mm Hg. What is the priority action?
A) Reorient the client and dim the lights
B) Administer prescribed PRN opioid analgesic
C) Elevate the head of the bed 30 degrees and notify the provider
D) Instruct the client to take slow, deep breaths
Correct Answer: C) Elevate the head of the bed 30 degrees and notify the provider
Rationale: Restlessness, headache, anisocoria (unequal pupils), and widened pulse pressure
indicate rising intracranial pressure (ICP). Elevating the head of the bed to 30° promotes venous
drainage from the brain and helps decrease ICP. The provider must be notified immediately.
Opioids can mask neurologic changes, and other options do not address the life-threatening ICP.
2. A client with increased intracranial pressure (ICP) is receiving mechanical ventilation. Which
ventilator setting change should the nurse question?
A) Increasing the respiratory rate to lower PaCO₂
B) Increasing positive end-expiratory pressure (PEEP)
C) Maintaining FiO₂ at 40%
D) Keeping tidal volume within normal range
,Correct Answer: B) Increasing positive end-expiratory pressure (PEEP)
Rationale: High PEEP increases intrathoracic pressure, which can reduce venous return from the
brain and worsen ICP. Mild hyperventilation (lower PaCO₂) causes cerebral vasoconstriction and
can help lower ICP short term, and normal tidal volume and FiO₂ are not problematic.
3. The nurse is assessing a client with a head injury. Which finding is the earliest indicator of
increased intracranial pressure?
A) Cushing's triad
B) Change in level of consciousness
C) Pupillary changes
D) Motor posturing
Correct Answer: B) Change in level of consciousness
Rationale: A change in level of consciousness (LOC) is the earliest and most reliable indicator of
increased ICP. Cushing's triad, pupillary changes, and motor posturing are later signs.
4. A client with increased ICP exhibits a blood pressure of 180/100 mmHg, heart rate of 52 bpm,
and irregular respirations. The nurse should recognize this as:
A) Normal vital signs
B) Cushing's triad
C) Signs of shock
D) Side effects of medication
, Correct Answer: B) Cushing's triad
Rationale: Cushing's triad (hypertension, bradycardia, and irregular respirations) is a late sign of
increased ICP and indicates impending herniation, requiring immediate intervention.
5. A client is experiencing a generalized tonic-clonic seizure. Which nursing action is most
appropriate?
A) Restrain the client to prevent injury
B) Place a tongue blade in the client's mouth
C) Protect the client's head and turn them to the side
D) Administer oral medications
Correct Answer: C) Protect the client's head and turn them to the side
Rationale: During a seizure, the nurse should protect the client's head and turn them to the side
to prevent aspiration. Restraints should never be used during a seizure, and nothing should be
placed in the client's mouth. Oral medications should not be given during a seizure.
6. A client is in the postictal phase after a seizure. Which assessment finding is most consistent
with this phase?
A) Hyperactivity and agitation
B) Confusion and drowsiness
C) Immediate return to baseline mental status
