,NSG 233 Medical-Surgical Nursing III Exam 2 |
Herzing | Latest 2026/2027 Update (PDF)
1. A client with a closed head injury exhibits flexion of the upper extremities and extension of the
lower extremities. Which nursing action is most appropriate?
A) Document the finding as decerebrate posturing
B) Document the finding as decorticate posturing
C) Prepare for immediate surgical decompression
D) Administer a muscle relaxant as prescribed
Correct Answer: Document the finding as decorticate posturing
Rationale: Decorticate posturing (abnormal flexion) is characterized by flexion of the arms, wrists, and
fingers with extension of the lower extremities. It indicates damage to the cerebral hemispheres or
internal capsule. Decerebrate posturing involves extension of both upper and lower extremities and
indicates brainstem damage. Surgical decompression is not indicated based solely on posturing, and
muscle relaxants are not the priority intervention.
2. A nurse is assessing a client for signs of increasing intracranial pressure (ICP). Which vital sign
pattern is most consistent with Cushing's triad?
A) Hypertension, bradycardia, and irregular respirations
B) Hypotension, tachycardia, and tachypnea
C) Hypertension, tachycardia, and tachypnea
D) Hypotension, bradycardia, and irregular respirations
Correct Answer: Hypertension, bradycardia, and irregular respirations
Rationale: Cushing's triad is a late sign of increased ICP and impending herniation, consisting of
hypertension (with widening pulse pressure), bradycardia, and irregular respirations (Cheyne-Stokes).
This triad indicates brainstem compression and requires immediate intervention. Hypotension and
tachycardia are not characteristic of increasing ICP.
,3. A client with a traumatic brain injury (TBI) has a Glasgow Coma Scale (GCS) score of 7. Which
nursing action is the priority?
A) Assess the client's level of consciousness every 4 hours
B) Prepare for intubation and mechanical ventilation
C) Administer sedatives to reduce intracranial pressure
D) Position the client in the supine position
Correct Answer: Prepare for intubation and mechanical ventilation
Rationale: A GCS score of 8 or less indicates severe brain injury and the need for airway protection.
The client is at risk for aspiration and respiratory failure. Intubation and mechanical ventilation are
the priority to maintain airway patency and oxygenation. Frequent neurological assessments, ICP
management, and positioning are important but secondary to airway protection.
4. A nurse is caring for a client with a spinal cord injury at the T6 level. The client develops a severe
pounding headache, hypertension, and bradycardia. Which condition should the nurse suspect?
A) Neurogenic shock
B) Autonomic dysreflexia
C) Spinal shock
D) Increased intracranial pressure
Correct Answer: Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a life-threatening emergency that occurs in clients with spinal cord
injuries at or above the T6 level. It is characterized by a severe pounding headache, paroxysmal
hypertension, diaphoresis above the level of the lesion, and bradycardia. Neurogenic shock presents
with hypotension and bradycardia, spinal shock presents with flaccid paralysis and loss of reflexes,
and increased ICP presents with Cushing's triad.
5. A client is admitted with a suspected acute ischemic stroke. The nurse knows that the window of
opportunity for administering alteplase (tPA) is within how many hours of symptom onset?
A) 1.5 hours
, B) 3 hours
C) 6 hours
D) 12 hours
Correct Answer: 3 hours
Rationale: Alteplase (tPA) is a thrombolytic agent used to dissolve the clot in an ischemic stroke. It
must be administered within 3 to 4.5 hours of the onset of symptoms to be effective and reduce the
risk of hemorrhagic transformation. Administration beyond this window increases the risk of bleeding
without significant benefit. Prompt recognition and treatment are essential for optimal outcomes.
6. A client with a suspected cerebrovascular accident (CVA) is being evaluated for tPA therapy. Which
finding is an absolute contraindication to tPA administration?
A) Onset of symptoms less than 3 hours ago
B) Blood pressure of 150/90 mmHg
C) History of intracranial hemorrhage
D) Age greater than 80 years
Correct Answer: History of intracranial hemorrhage
Rationale: A history of intracranial hemorrhage is an absolute contraindication to tPA administration
due to the risk of causing or worsening bleeding. Onset of symptoms less than 3 hours is an indication
for tPA. Blood pressure of 150/90 mmHg is acceptable if controlled. Age greater than 80 years is a
relative but not absolute contraindication.
7. A nurse is assessing a client who has suffered a mild traumatic brain injury (TBI). Which finding
would indicate increasing intracranial pressure?
A) Increased systolic blood pressure, widening pulse pressure, and bradycardia
B) Decreased systolic blood pressure, narrowing pulse pressure, and tachycardia
C) Hypotension, tachycardia, and tachypnea
D) Hypertension, tachycardia, and tachypnea
Herzing | Latest 2026/2027 Update (PDF)
1. A client with a closed head injury exhibits flexion of the upper extremities and extension of the
lower extremities. Which nursing action is most appropriate?
A) Document the finding as decerebrate posturing
B) Document the finding as decorticate posturing
C) Prepare for immediate surgical decompression
D) Administer a muscle relaxant as prescribed
Correct Answer: Document the finding as decorticate posturing
Rationale: Decorticate posturing (abnormal flexion) is characterized by flexion of the arms, wrists, and
fingers with extension of the lower extremities. It indicates damage to the cerebral hemispheres or
internal capsule. Decerebrate posturing involves extension of both upper and lower extremities and
indicates brainstem damage. Surgical decompression is not indicated based solely on posturing, and
muscle relaxants are not the priority intervention.
2. A nurse is assessing a client for signs of increasing intracranial pressure (ICP). Which vital sign
pattern is most consistent with Cushing's triad?
A) Hypertension, bradycardia, and irregular respirations
B) Hypotension, tachycardia, and tachypnea
C) Hypertension, tachycardia, and tachypnea
D) Hypotension, bradycardia, and irregular respirations
Correct Answer: Hypertension, bradycardia, and irregular respirations
Rationale: Cushing's triad is a late sign of increased ICP and impending herniation, consisting of
hypertension (with widening pulse pressure), bradycardia, and irregular respirations (Cheyne-Stokes).
This triad indicates brainstem compression and requires immediate intervention. Hypotension and
tachycardia are not characteristic of increasing ICP.
,3. A client with a traumatic brain injury (TBI) has a Glasgow Coma Scale (GCS) score of 7. Which
nursing action is the priority?
A) Assess the client's level of consciousness every 4 hours
B) Prepare for intubation and mechanical ventilation
C) Administer sedatives to reduce intracranial pressure
D) Position the client in the supine position
Correct Answer: Prepare for intubation and mechanical ventilation
Rationale: A GCS score of 8 or less indicates severe brain injury and the need for airway protection.
The client is at risk for aspiration and respiratory failure. Intubation and mechanical ventilation are
the priority to maintain airway patency and oxygenation. Frequent neurological assessments, ICP
management, and positioning are important but secondary to airway protection.
4. A nurse is caring for a client with a spinal cord injury at the T6 level. The client develops a severe
pounding headache, hypertension, and bradycardia. Which condition should the nurse suspect?
A) Neurogenic shock
B) Autonomic dysreflexia
C) Spinal shock
D) Increased intracranial pressure
Correct Answer: Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a life-threatening emergency that occurs in clients with spinal cord
injuries at or above the T6 level. It is characterized by a severe pounding headache, paroxysmal
hypertension, diaphoresis above the level of the lesion, and bradycardia. Neurogenic shock presents
with hypotension and bradycardia, spinal shock presents with flaccid paralysis and loss of reflexes,
and increased ICP presents with Cushing's triad.
5. A client is admitted with a suspected acute ischemic stroke. The nurse knows that the window of
opportunity for administering alteplase (tPA) is within how many hours of symptom onset?
A) 1.5 hours
, B) 3 hours
C) 6 hours
D) 12 hours
Correct Answer: 3 hours
Rationale: Alteplase (tPA) is a thrombolytic agent used to dissolve the clot in an ischemic stroke. It
must be administered within 3 to 4.5 hours of the onset of symptoms to be effective and reduce the
risk of hemorrhagic transformation. Administration beyond this window increases the risk of bleeding
without significant benefit. Prompt recognition and treatment are essential for optimal outcomes.
6. A client with a suspected cerebrovascular accident (CVA) is being evaluated for tPA therapy. Which
finding is an absolute contraindication to tPA administration?
A) Onset of symptoms less than 3 hours ago
B) Blood pressure of 150/90 mmHg
C) History of intracranial hemorrhage
D) Age greater than 80 years
Correct Answer: History of intracranial hemorrhage
Rationale: A history of intracranial hemorrhage is an absolute contraindication to tPA administration
due to the risk of causing or worsening bleeding. Onset of symptoms less than 3 hours is an indication
for tPA. Blood pressure of 150/90 mmHg is acceptable if controlled. Age greater than 80 years is a
relative but not absolute contraindication.
7. A nurse is assessing a client who has suffered a mild traumatic brain injury (TBI). Which finding
would indicate increasing intracranial pressure?
A) Increased systolic blood pressure, widening pulse pressure, and bradycardia
B) Decreased systolic blood pressure, narrowing pulse pressure, and tachycardia
C) Hypotension, tachycardia, and tachypnea
D) Hypertension, tachycardia, and tachypnea
