NUR 265 Exam 3 Version 1 and 2 New | Actual Questions
and Answers | 2026 Update | 100% Correct - Galen College
of Nursing.
TBI / ICP
1. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
B) Document the finding but take no additional action.
C) Address a less urgent problem before this finding.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: A) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
2. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Reassure the client and wait until the next routine assessment.
B) Address a less urgent problem before this finding.
C) Document the finding but take no additional action.
D) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
Correct Answer: D) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
3. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Reassure the client and wait until the next routine assessment.
B) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
C) Document the finding but take no additional action.
D) Address a less urgent problem before this finding.
Correct Answer: B) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
,Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
4. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
B) Address a less urgent problem before this finding.
C) Reassure the client and wait until the next routine assessment.
D) Document the finding but take no additional action.
Correct Answer: A) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
5. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Address a less urgent problem before this finding.
B) Document the finding but take no additional action.
C) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: C) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
6. Which intervention is appropriate for a client at risk for increased intracranial pressure?
A) Address a less urgent problem before this finding.
B) Keep the head midline and elevate the head of the bed as prescribed.
C) Document the finding but take no additional action.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: B) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
7. A nurse is reviewing the client situation. Which intervention is appropriate for a client at risk for
increased intracranial pressure?
A) Document the finding but take no additional action.
B) Keep the head midline and elevate the head of the bed as prescribed.
, C) Reassure the client and wait until the next routine assessment.
D) Address a less urgent problem before this finding.
Correct Answer: B) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
8. During a change-of-shift assessment, which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Keep the head midline and elevate the head of the bed as prescribed.
B) Reassure the client and wait until the next routine assessment.
C) Document the finding but take no additional action.
D) Address a less urgent problem before this finding.
Correct Answer: A) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
9. For an NCLEX-style priority question, which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Keep the head midline and elevate the head of the bed as prescribed.
B) Address a less urgent problem before this finding.
C) Document the finding but take no additional action.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: A) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
10. The nurse is preparing the plan of care. Which intervention is appropriate for a client at risk for
increased intracranial pressure?
A) Reassure the client and wait until the next routine assessment.
B) Keep the head midline and elevate the head of the bed as prescribed.
C) Address a less urgent problem before this finding.
D) Document the finding but take no additional action.
Correct Answer: B) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
11. Which finding is most concerning for increasing intracranial pressure?
, A) Address a less urgent problem before this finding.
B) Document the finding but take no additional action.
C) Reassure the client and wait until the next routine assessment.
D) Declining level of consciousness.
Correct Answer: D) Declining level of consciousness.
Rationale: A change in level of consciousness can be an early and important indicator of neurologic
deterioration.
12. A nurse is reviewing the client situation. Which finding is most concerning for increasing intracranial
pressure?
A) Address a less urgent problem before this finding.
B) Document the finding but take no additional action.
C) Declining level of consciousness.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: C) Declining level of consciousness.
Rationale: A change in level of consciousness can be an early and important indicator of neurologic
deterioration.
13. During a change-of-shift assessment, which finding is most concerning for increasing intracranial
pressure?
A) Document the finding but take no additional action.
B) Address a less urgent problem before this finding.
C) Reassure the client and wait until the next routine assessment.
D) Declining level of consciousness.
Correct Answer: D) Declining level of consciousness.
Rationale: A change in level of consciousness can be an early and important indicator of neurologic
deterioration.
14. For an NCLEX-style priority question, which finding is most concerning for increasing intracranial
pressure?
A) Reassure the client and wait until the next routine assessment.
B) Address a less urgent problem before this finding.
C) Document the finding but take no additional action.
D) Declining level of consciousness.
Correct Answer: D) Declining level of consciousness.
and Answers | 2026 Update | 100% Correct - Galen College
of Nursing.
TBI / ICP
1. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
B) Document the finding but take no additional action.
C) Address a less urgent problem before this finding.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: A) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
2. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Reassure the client and wait until the next routine assessment.
B) Address a less urgent problem before this finding.
C) Document the finding but take no additional action.
D) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
Correct Answer: D) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
3. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Reassure the client and wait until the next routine assessment.
B) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
C) Document the finding but take no additional action.
D) Address a less urgent problem before this finding.
Correct Answer: B) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
,Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
4. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
B) Address a less urgent problem before this finding.
C) Reassure the client and wait until the next routine assessment.
D) Document the finding but take no additional action.
Correct Answer: A) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
5. A client with a traumatic brain injury has a new unequal, nonreactive pupil. What is the priority nursing
action?
A) Address a less urgent problem before this finding.
B) Document the finding but take no additional action.
C) Notify the provider/rapid-response team and perform an immediate neurologic reassessment.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: C) Notify the provider/rapid-response team and perform an immediate neurologic
reassessment.
Rationale: A new fixed or unequal pupil can indicate neurologic deterioration and possible herniation,
requiring urgent escalation.
6. Which intervention is appropriate for a client at risk for increased intracranial pressure?
A) Address a less urgent problem before this finding.
B) Keep the head midline and elevate the head of the bed as prescribed.
C) Document the finding but take no additional action.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: B) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
7. A nurse is reviewing the client situation. Which intervention is appropriate for a client at risk for
increased intracranial pressure?
A) Document the finding but take no additional action.
B) Keep the head midline and elevate the head of the bed as prescribed.
, C) Reassure the client and wait until the next routine assessment.
D) Address a less urgent problem before this finding.
Correct Answer: B) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
8. During a change-of-shift assessment, which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Keep the head midline and elevate the head of the bed as prescribed.
B) Reassure the client and wait until the next routine assessment.
C) Document the finding but take no additional action.
D) Address a less urgent problem before this finding.
Correct Answer: A) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
9. For an NCLEX-style priority question, which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Keep the head midline and elevate the head of the bed as prescribed.
B) Address a less urgent problem before this finding.
C) Document the finding but take no additional action.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: A) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
10. The nurse is preparing the plan of care. Which intervention is appropriate for a client at risk for
increased intracranial pressure?
A) Reassure the client and wait until the next routine assessment.
B) Keep the head midline and elevate the head of the bed as prescribed.
C) Address a less urgent problem before this finding.
D) Document the finding but take no additional action.
Correct Answer: B) Keep the head midline and elevate the head of the bed as prescribed.
Rationale: Head elevation and neutral alignment can promote venous drainage and help limit increases in
intracranial pressure.
11. Which finding is most concerning for increasing intracranial pressure?
, A) Address a less urgent problem before this finding.
B) Document the finding but take no additional action.
C) Reassure the client and wait until the next routine assessment.
D) Declining level of consciousness.
Correct Answer: D) Declining level of consciousness.
Rationale: A change in level of consciousness can be an early and important indicator of neurologic
deterioration.
12. A nurse is reviewing the client situation. Which finding is most concerning for increasing intracranial
pressure?
A) Address a less urgent problem before this finding.
B) Document the finding but take no additional action.
C) Declining level of consciousness.
D) Reassure the client and wait until the next routine assessment.
Correct Answer: C) Declining level of consciousness.
Rationale: A change in level of consciousness can be an early and important indicator of neurologic
deterioration.
13. During a change-of-shift assessment, which finding is most concerning for increasing intracranial
pressure?
A) Document the finding but take no additional action.
B) Address a less urgent problem before this finding.
C) Reassure the client and wait until the next routine assessment.
D) Declining level of consciousness.
Correct Answer: D) Declining level of consciousness.
Rationale: A change in level of consciousness can be an early and important indicator of neurologic
deterioration.
14. For an NCLEX-style priority question, which finding is most concerning for increasing intracranial
pressure?
A) Reassure the client and wait until the next routine assessment.
B) Address a less urgent problem before this finding.
C) Document the finding but take no additional action.
D) Declining level of consciousness.
Correct Answer: D) Declining level of consciousness.
