,NUR 265 ATI Advanced Concepts of Medical-Surgical Nursing
Questions And Answers 2026/2027 Galen College
Q1. A nurse is caring for a client with increased intracranial
pressure (ICP). Which finding should the nurse report immediately?
A) Glasgow Coma Scale score decreases from 14 to 11
B) Heart rate of 88/min
C) Temperature of 37.1°C (98.8°F)
D) Pupils equal and reactive to light
Correct Answer: A) Glasgow Coma Scale score decreases from 14 to 11
Rationale: A significant decrease in the Glasgow Coma Scale score indicates
worsening neurologic function and can be a sign of increasing ICP.
Q2. Which assessment finding is associated with Cushing's triad?
A) Tachycardia, hypotension, and tachypnea
B) Hypertension, bradycardia, and widened pulse pressure
C) Hypotension, tachycardia, and narrow pulse pressure
D) Hypertension, tachycardia, and fever
Correct Answer: B) Hypertension, bradycardia, and widened pulse pressure
Rationale: Cushing's triad is a late manifestation of increased ICP
characterized by hypertension with widened pulse pressure, bradycardia,
and abnormal respirations.
Q3. Which position should the nurse use for a client with increased
ICP?
A) Flat with the neck flexed
B) Trendelenburg
C) Head of bed elevated with the head in neutral alignment
D) Prone with the head turned to the side
Correct Answer: C) Head of bed elevated with the head in neutral alignment
Rationale: Elevating the head and maintaining neutral neck alignment
promotes venous drainage from the brain and can help reduce ICP.
Q4. Which nursing intervention is appropriate for a client with
increased ICP?
A) Cluster all nursing care together
B) Maintain a quiet environment and minimize unnecessary stimulation
C) Encourage frequent coughing
D) Keep the client in Trendelenburg position
, Correct Answer: B) Maintain a quiet environment and minimize unnecessary
stimulation
Rationale: Excessive stimulation and activities that increase intrathoracic
pressure can increase ICP.
Q5. A client with a traumatic brain injury develops unequal pupils.
What should the nurse do?
A) Document the finding as expected
B) Reassess in 8 hours
C) Notify the provider immediately
D) Encourage oral fluids
Correct Answer: C) Notify the provider immediately
Rationale: New unequal pupils can indicate neurologic deterioration and
increased intracranial pressure.
Q6. Which finding is an early indicator of increased ICP?
A) Change in level of consciousness
B) Cushing's triad
C) Fixed and dilated pupils
D) Respiratory arrest
Correct Answer: A) Change in level of consciousness
Rationale: A change in level of consciousness is often one of the earliest
signs of increasing ICP.
Q7. A client with a head injury has clear drainage from the nose.
Which action should the nurse take?
A) Insert nasal packing
B) Test the drainage for cerebrospinal fluid as prescribed
C) Suction the nose deeply
D) Encourage the client to blow the nose
Correct Answer: B) Test the drainage for cerebrospinal fluid as prescribed
Rationale: Clear drainage after head trauma can indicate a cerebrospinal
fluid leak and requires evaluation.
Q8. Which finding is associated with a basilar skull fracture?
A) Battle sign
B) Cullen sign
Questions And Answers 2026/2027 Galen College
Q1. A nurse is caring for a client with increased intracranial
pressure (ICP). Which finding should the nurse report immediately?
A) Glasgow Coma Scale score decreases from 14 to 11
B) Heart rate of 88/min
C) Temperature of 37.1°C (98.8°F)
D) Pupils equal and reactive to light
Correct Answer: A) Glasgow Coma Scale score decreases from 14 to 11
Rationale: A significant decrease in the Glasgow Coma Scale score indicates
worsening neurologic function and can be a sign of increasing ICP.
Q2. Which assessment finding is associated with Cushing's triad?
A) Tachycardia, hypotension, and tachypnea
B) Hypertension, bradycardia, and widened pulse pressure
C) Hypotension, tachycardia, and narrow pulse pressure
D) Hypertension, tachycardia, and fever
Correct Answer: B) Hypertension, bradycardia, and widened pulse pressure
Rationale: Cushing's triad is a late manifestation of increased ICP
characterized by hypertension with widened pulse pressure, bradycardia,
and abnormal respirations.
Q3. Which position should the nurse use for a client with increased
ICP?
A) Flat with the neck flexed
B) Trendelenburg
C) Head of bed elevated with the head in neutral alignment
D) Prone with the head turned to the side
Correct Answer: C) Head of bed elevated with the head in neutral alignment
Rationale: Elevating the head and maintaining neutral neck alignment
promotes venous drainage from the brain and can help reduce ICP.
Q4. Which nursing intervention is appropriate for a client with
increased ICP?
A) Cluster all nursing care together
B) Maintain a quiet environment and minimize unnecessary stimulation
C) Encourage frequent coughing
D) Keep the client in Trendelenburg position
, Correct Answer: B) Maintain a quiet environment and minimize unnecessary
stimulation
Rationale: Excessive stimulation and activities that increase intrathoracic
pressure can increase ICP.
Q5. A client with a traumatic brain injury develops unequal pupils.
What should the nurse do?
A) Document the finding as expected
B) Reassess in 8 hours
C) Notify the provider immediately
D) Encourage oral fluids
Correct Answer: C) Notify the provider immediately
Rationale: New unequal pupils can indicate neurologic deterioration and
increased intracranial pressure.
Q6. Which finding is an early indicator of increased ICP?
A) Change in level of consciousness
B) Cushing's triad
C) Fixed and dilated pupils
D) Respiratory arrest
Correct Answer: A) Change in level of consciousness
Rationale: A change in level of consciousness is often one of the earliest
signs of increasing ICP.
Q7. A client with a head injury has clear drainage from the nose.
Which action should the nurse take?
A) Insert nasal packing
B) Test the drainage for cerebrospinal fluid as prescribed
C) Suction the nose deeply
D) Encourage the client to blow the nose
Correct Answer: B) Test the drainage for cerebrospinal fluid as prescribed
Rationale: Clear drainage after head trauma can indicate a cerebrospinal
fluid leak and requires evaluation.
Q8. Which finding is associated with a basilar skull fracture?
A) Battle sign
B) Cullen sign
