,NSG 233 Exam 2 Medical-Surgical Nursing III Questions And
Answers 2026/2027 Herzing University
Q1. Which assessment finding is an early indicator of neurologic
deterioration in a client with a traumatic brain injury?
A) Tachycardia
B) Restlessness and changes in level of consciousness
C) Increased appetite
D) Increased urine output
Correct Answer: B) Restlessness and changes in level of consciousness
Rationale: Early neurologic changes such as restlessness, confusion, and
decreasing level of consciousness can indicate worsening cerebral function
before late signs of increased intracranial pressure develop.
Q2. Which tool is commonly used to assess the level of consciousness in a
client with traumatic brain injury?
A) Glasgow Coma Scale
B) Braden Scale
C) Apgar score
D) Morse Fall Scale
Correct Answer: A) Glasgow Coma Scale
Rationale: The Glasgow Coma Scale evaluates eye opening, verbal
response, and motor response to quantify neurologic status.
Q3. A client has a Glasgow Coma Scale score of 7 after a traumatic brain
injury. How should the nurse interpret this finding?
A) Mild neurologic impairment
B) Moderate neurologic impairment
C) Severe neurologic impairment
D) Normal neurologic function
Correct Answer: C) Severe neurologic impairment
Rationale: A GCS score of 8 or less indicates severe neurologic impairment
and commonly prompts consideration of airway protection.
Q4. Which finding is part of Cushing's triad?
A) Bradycardia
B) Tachycardia
C) Hypotension
D) Narrowing pulse pressure
Correct Answer: A) Bradycardia
Rationale: Cushing's triad consists of hypertension with widening pulse
, pressure, bradycardia, and irregular respirations and is a late sign of
significantly increased intracranial pressure.
Q5. Which additional finding is associated with Cushing's triad?
A) Widening pulse pressure
B) Hypotension
C) Tachycardia
D) Regular respirations
Correct Answer: A) Widening pulse pressure
Rationale: Increasing systolic pressure with relatively lower diastolic
pressure produces a widened pulse pressure as intracranial pressure rises.
Q6. Which position is generally appropriate for a client with increased
intracranial pressure?
A) Head of bed elevated approximately 30 degrees with the neck neutral
B) Trendelenburg
C) Flat with the neck flexed
D) Prone with the head turned
Correct Answer: A) Head of bed elevated approximately 30 degrees with the
neck neutral
Rationale: Moderate head elevation and neutral neck alignment promote
venous drainage from the brain and may help decrease intracranial pressure.
Q7. Which action should the nurse avoid in a client with increased
intracranial pressure?
A) Maintaining a neutral head position
B) Avoiding unnecessary stimulation
C) Encouraging repeated coughing and straining
D) Monitoring neurologic status
Correct Answer: C) Encouraging repeated coughing and straining
Rationale: Coughing and straining increase intrathoracic and intracranial
pressure and may worsen cerebral perfusion.
Q8. Which finding may indicate increasing intracranial pressure?
A) Unequal pupils
B) Increased appetite
C) Improved level of consciousness
D) Normal neurologic assessment
Correct Answer: A) Unequal pupils
Rationale: Pupillary changes can indicate compression of cranial nerves and
worsening intracranial pressure.
Answers 2026/2027 Herzing University
Q1. Which assessment finding is an early indicator of neurologic
deterioration in a client with a traumatic brain injury?
A) Tachycardia
B) Restlessness and changes in level of consciousness
C) Increased appetite
D) Increased urine output
Correct Answer: B) Restlessness and changes in level of consciousness
Rationale: Early neurologic changes such as restlessness, confusion, and
decreasing level of consciousness can indicate worsening cerebral function
before late signs of increased intracranial pressure develop.
Q2. Which tool is commonly used to assess the level of consciousness in a
client with traumatic brain injury?
A) Glasgow Coma Scale
B) Braden Scale
C) Apgar score
D) Morse Fall Scale
Correct Answer: A) Glasgow Coma Scale
Rationale: The Glasgow Coma Scale evaluates eye opening, verbal
response, and motor response to quantify neurologic status.
Q3. A client has a Glasgow Coma Scale score of 7 after a traumatic brain
injury. How should the nurse interpret this finding?
A) Mild neurologic impairment
B) Moderate neurologic impairment
C) Severe neurologic impairment
D) Normal neurologic function
Correct Answer: C) Severe neurologic impairment
Rationale: A GCS score of 8 or less indicates severe neurologic impairment
and commonly prompts consideration of airway protection.
Q4. Which finding is part of Cushing's triad?
A) Bradycardia
B) Tachycardia
C) Hypotension
D) Narrowing pulse pressure
Correct Answer: A) Bradycardia
Rationale: Cushing's triad consists of hypertension with widening pulse
, pressure, bradycardia, and irregular respirations and is a late sign of
significantly increased intracranial pressure.
Q5. Which additional finding is associated with Cushing's triad?
A) Widening pulse pressure
B) Hypotension
C) Tachycardia
D) Regular respirations
Correct Answer: A) Widening pulse pressure
Rationale: Increasing systolic pressure with relatively lower diastolic
pressure produces a widened pulse pressure as intracranial pressure rises.
Q6. Which position is generally appropriate for a client with increased
intracranial pressure?
A) Head of bed elevated approximately 30 degrees with the neck neutral
B) Trendelenburg
C) Flat with the neck flexed
D) Prone with the head turned
Correct Answer: A) Head of bed elevated approximately 30 degrees with the
neck neutral
Rationale: Moderate head elevation and neutral neck alignment promote
venous drainage from the brain and may help decrease intracranial pressure.
Q7. Which action should the nurse avoid in a client with increased
intracranial pressure?
A) Maintaining a neutral head position
B) Avoiding unnecessary stimulation
C) Encouraging repeated coughing and straining
D) Monitoring neurologic status
Correct Answer: C) Encouraging repeated coughing and straining
Rationale: Coughing and straining increase intrathoracic and intracranial
pressure and may worsen cerebral perfusion.
Q8. Which finding may indicate increasing intracranial pressure?
A) Unequal pupils
B) Increased appetite
C) Improved level of consciousness
D) Normal neurologic assessment
Correct Answer: A) Unequal pupils
Rationale: Pupillary changes can indicate compression of cranial nerves and
worsening intracranial pressure.
