,NUR 2790 Final Exam | Professional Nursing III (2026)
Actual Q&A PDF | Rasmussen College
1. Which clinical manifestation is the earliest indicator of increased intracranial
pressure (ICP) following a traumatic brain injury?
A) Pupillary dilation and fixation
B) Cushing's triad with bradycardia
C) A change in the patient's level of consciousness
D) Decerebrate posturing of the extremities
Correct Answer: A change in the patient's level of consciousness
Rationale: A change in level of consciousness (LOC) is the most sensitive and earliest
indicator of rising ICP. As pressure increases, cerebral perfusion decreases, affecting
the reticular activating system. Pupillary changes, Cushing's triad, and posturing are
late signs indicating brainstem compression and herniation.
2. A 72-year-old patient with a history of atrial fibrillation suddenly develops right-
sided weakness, facial droop, and expressive aphasia. The patient's last known well
time was 90 minutes ago. Which immediate action should the nurse prioritize?
A) Prepare the patient for a carotid endarterectomy
B) Administer a bolus of 0.9% normal saline
C) Notify the stroke team and prepare for a non-contrast CT scan
D) Give 325 mg of aspirin rectally
Correct Answer: Notify the stroke team and prepare for a non-contrast CT scan
,Rationale: This patient is within the 3-4.5 hour window for thrombolytic therapy; the
immediate priority is to obtain a non-contrast CT scan to differentiate ischemic from
hemorrhagic stroke. The stroke team must be notified immediately. Aspirin is
contraindicated until hemorrhage is ruled out, and carotid endarterectomy is not an
acute intervention.
3. A nurse is caring for a patient with increased ICP from a brain tumor. Which
nursing intervention is most effective in helping to reduce ICP?
A) Place the patient in a flat, supine position
B) Cluster all nursing activities to minimize disturbances
C) Maintain the head of the bed at 30 degrees and keep the head in a neutral
position
D) Suction the airway vigorously to clear secretions
Correct Answer: Maintain the head of the bed at 30 degrees and keep the head in a
neutral position
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage
from the head, which helps reduce ICP. The head should be maintained in a neutral,
midline position to avoid jugular vein compression. Clustering activities can increase
ICP, and vigorous suctioning can cause a dangerous spike in ICP.
4. According to the Glasgow Coma Scale (GCS), which score indicates a severe
traumatic brain injury requiring immediate intubation for airway protection?
A) 13
B) 10
C) 8
D) 5
Correct Answer: 8
, Rationale: A GCS score of 8 or less is the established threshold for severe brain
injury and indicates the patient cannot protect their airway, necessitating immediate
intubation. A score of 9-12 indicates moderate injury, and 13-15 indicates mild injury.
5. A patient is admitted with a suspected subarachnoid hemorrhage. Which
diagnostic test is the gold standard for confirming this diagnosis?
A) Lumbar puncture
B) CT scan of the head without contrast
C) Magnetic resonance imaging (MRI)
D) Cerebral angiography
Correct Answer: CT scan of the head without contrast
Rationale: A non-contrast CT scan of the head is the gold standard initial diagnostic
test for subarachnoid hemorrhage, as it can detect blood in the subarachnoid space
with high sensitivity within the first 24 hours. A lumbar puncture is used if the CT is
negative but clinical suspicion remains high.
6. A patient is recovering from a right-sided stroke and presents with difficulty
swallowing and a weak cough. What is the priority nursing intervention to prevent
aspiration?
A) Place the patient in a semi-Fowler's position for meals
B) Consult a speech-language pathologist for a swallow evaluation
C) Offer thickened liquids only
D) Keep the patient NPO until the gag reflex returns
Correct Answer: Consult a speech-language pathologist for a swallow evaluation
Actual Q&A PDF | Rasmussen College
1. Which clinical manifestation is the earliest indicator of increased intracranial
pressure (ICP) following a traumatic brain injury?
A) Pupillary dilation and fixation
B) Cushing's triad with bradycardia
C) A change in the patient's level of consciousness
D) Decerebrate posturing of the extremities
Correct Answer: A change in the patient's level of consciousness
Rationale: A change in level of consciousness (LOC) is the most sensitive and earliest
indicator of rising ICP. As pressure increases, cerebral perfusion decreases, affecting
the reticular activating system. Pupillary changes, Cushing's triad, and posturing are
late signs indicating brainstem compression and herniation.
2. A 72-year-old patient with a history of atrial fibrillation suddenly develops right-
sided weakness, facial droop, and expressive aphasia. The patient's last known well
time was 90 minutes ago. Which immediate action should the nurse prioritize?
A) Prepare the patient for a carotid endarterectomy
B) Administer a bolus of 0.9% normal saline
C) Notify the stroke team and prepare for a non-contrast CT scan
D) Give 325 mg of aspirin rectally
Correct Answer: Notify the stroke team and prepare for a non-contrast CT scan
,Rationale: This patient is within the 3-4.5 hour window for thrombolytic therapy; the
immediate priority is to obtain a non-contrast CT scan to differentiate ischemic from
hemorrhagic stroke. The stroke team must be notified immediately. Aspirin is
contraindicated until hemorrhage is ruled out, and carotid endarterectomy is not an
acute intervention.
3. A nurse is caring for a patient with increased ICP from a brain tumor. Which
nursing intervention is most effective in helping to reduce ICP?
A) Place the patient in a flat, supine position
B) Cluster all nursing activities to minimize disturbances
C) Maintain the head of the bed at 30 degrees and keep the head in a neutral
position
D) Suction the airway vigorously to clear secretions
Correct Answer: Maintain the head of the bed at 30 degrees and keep the head in a
neutral position
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage
from the head, which helps reduce ICP. The head should be maintained in a neutral,
midline position to avoid jugular vein compression. Clustering activities can increase
ICP, and vigorous suctioning can cause a dangerous spike in ICP.
4. According to the Glasgow Coma Scale (GCS), which score indicates a severe
traumatic brain injury requiring immediate intubation for airway protection?
A) 13
B) 10
C) 8
D) 5
Correct Answer: 8
, Rationale: A GCS score of 8 or less is the established threshold for severe brain
injury and indicates the patient cannot protect their airway, necessitating immediate
intubation. A score of 9-12 indicates moderate injury, and 13-15 indicates mild injury.
5. A patient is admitted with a suspected subarachnoid hemorrhage. Which
diagnostic test is the gold standard for confirming this diagnosis?
A) Lumbar puncture
B) CT scan of the head without contrast
C) Magnetic resonance imaging (MRI)
D) Cerebral angiography
Correct Answer: CT scan of the head without contrast
Rationale: A non-contrast CT scan of the head is the gold standard initial diagnostic
test for subarachnoid hemorrhage, as it can detect blood in the subarachnoid space
with high sensitivity within the first 24 hours. A lumbar puncture is used if the CT is
negative but clinical suspicion remains high.
6. A patient is recovering from a right-sided stroke and presents with difficulty
swallowing and a weak cough. What is the priority nursing intervention to prevent
aspiration?
A) Place the patient in a semi-Fowler's position for meals
B) Consult a speech-language pathologist for a swallow evaluation
C) Offer thickened liquids only
D) Keep the patient NPO until the gag reflex returns
Correct Answer: Consult a speech-language pathologist for a swallow evaluation
