,Verified NUR 265 Exam 3 Test Bank & Guaranteed
Success Exam Prep Guide | Advanced Medical
Surgical Nursing | Galen College of Nursing
1. What is the normal range for intracranial pressure (ICP) in an adult?
A) 0 to 5 mm Hg
B) 10 to 15 mm Hg
C) 20 to 30 mm Hg
D) 35 to 45 mm Hg
Correct Answer: B) 10 to 15 mm Hg
Rationale: Normal ICP ranges from 10 to 15 mm Hg. Sustained pressures at or above 20 mm Hg
can cause brain neurons to die due to impaired cerebral perfusion. Early recognition of rising
ICP is critical to prevent irreversible neurological injury.
2. Which triad of findings characterizes Cushing's triad in a patient with increased intracranial
pressure?
A) Hypotension, tachycardia, and tachypnea
B) Hypertension, bradycardia, and irregular respirations
C) Hypertension, tachycardia, and hyperthermia
D) Hypotension, bradycardia, and hypothermia
,Correct Answer: B) Hypertension, bradycardia, and irregular respirations
Rationale: Cushing's triad consists of severe hypertension with a widening pulse pressure,
bradycardia, and irregular respirations. It is a late and ominous sign of increased ICP indicating
brainstem compression and impending herniation.
3. Which assessment finding is the earliest indicator of increasing intracranial pressure?
A) Fixed and dilated pupils
B) Decerebrate posturing
C) A change in level of consciousness
D) Cushing's triad
Correct Answer: C) A change in level of consciousness
Rationale: A change in LOC is the earliest and most sensitive sign of increasing ICP. Restlessness,
irritability, or drowsiness may precede pupillary changes, motor abnormalities, and Cushing's
triad, all of which are later manifestations.
4. The nurse is caring for an adult client who was recently admitted with a head injury following
a motor vehicle crash. One hour ago, the client's vital signs were: T 98.6°F, P 110, R 26, BP
128/68 mm Hg. The current VS are: P 56, R 14, BP 166/52 mm Hg. Which finding is a priority for
the nurse to follow up?
A) Pulse 56 bpm
B) Respirations 14 per minute
, C) Blood pressure 166/52 mm Hg
D) Temperature 98.6°F
Correct Answer: A) Pulse 56 bpm
Rationale: Bradycardia combined with hypertension and irregular respirations may indicate
Cushing's triad, a classic sign of increased ICP and impending brain herniation. The decrease in
pulse rate from 110 to 56 bpm with a rising blood pressure is an ominous neurological sign
requiring immediate attention. The respiratory rate of 14 is within normal limits.
5. A client with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. What is the
priority action?
A) Administer IV fluids
B) Prepare for intubation and mechanical ventilation
C) Apply cervical collar only
D) Obtain a CT scan immediately
Correct Answer: B) Prepare for intubation and mechanical ventilation
Rationale: A GCS ≤8 indicates coma and inability to protect the airway. Securing the airway via
intubation is the priority per ABCs (Airway, Breathing, Circulation). While imaging is essential,
airway protection comes first to prevent hypoxia and secondary brain injury.
Success Exam Prep Guide | Advanced Medical
Surgical Nursing | Galen College of Nursing
1. What is the normal range for intracranial pressure (ICP) in an adult?
A) 0 to 5 mm Hg
B) 10 to 15 mm Hg
C) 20 to 30 mm Hg
D) 35 to 45 mm Hg
Correct Answer: B) 10 to 15 mm Hg
Rationale: Normal ICP ranges from 10 to 15 mm Hg. Sustained pressures at or above 20 mm Hg
can cause brain neurons to die due to impaired cerebral perfusion. Early recognition of rising
ICP is critical to prevent irreversible neurological injury.
2. Which triad of findings characterizes Cushing's triad in a patient with increased intracranial
pressure?
A) Hypotension, tachycardia, and tachypnea
B) Hypertension, bradycardia, and irregular respirations
C) Hypertension, tachycardia, and hyperthermia
D) Hypotension, bradycardia, and hypothermia
,Correct Answer: B) Hypertension, bradycardia, and irregular respirations
Rationale: Cushing's triad consists of severe hypertension with a widening pulse pressure,
bradycardia, and irregular respirations. It is a late and ominous sign of increased ICP indicating
brainstem compression and impending herniation.
3. Which assessment finding is the earliest indicator of increasing intracranial pressure?
A) Fixed and dilated pupils
B) Decerebrate posturing
C) A change in level of consciousness
D) Cushing's triad
Correct Answer: C) A change in level of consciousness
Rationale: A change in LOC is the earliest and most sensitive sign of increasing ICP. Restlessness,
irritability, or drowsiness may precede pupillary changes, motor abnormalities, and Cushing's
triad, all of which are later manifestations.
4. The nurse is caring for an adult client who was recently admitted with a head injury following
a motor vehicle crash. One hour ago, the client's vital signs were: T 98.6°F, P 110, R 26, BP
128/68 mm Hg. The current VS are: P 56, R 14, BP 166/52 mm Hg. Which finding is a priority for
the nurse to follow up?
A) Pulse 56 bpm
B) Respirations 14 per minute
, C) Blood pressure 166/52 mm Hg
D) Temperature 98.6°F
Correct Answer: A) Pulse 56 bpm
Rationale: Bradycardia combined with hypertension and irregular respirations may indicate
Cushing's triad, a classic sign of increased ICP and impending brain herniation. The decrease in
pulse rate from 110 to 56 bpm with a rising blood pressure is an ominous neurological sign
requiring immediate attention. The respiratory rate of 14 is within normal limits.
5. A client with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. What is the
priority action?
A) Administer IV fluids
B) Prepare for intubation and mechanical ventilation
C) Apply cervical collar only
D) Obtain a CT scan immediately
Correct Answer: B) Prepare for intubation and mechanical ventilation
Rationale: A GCS ≤8 indicates coma and inability to protect the airway. Securing the airway via
intubation is the priority per ABCs (Airway, Breathing, Circulation). While imaging is essential,
airway protection comes first to prevent hypoxia and secondary brain injury.
