NSG 4100 Exam 4 Final | Latest Update 2026/2027 |
200 Practice Questions & Detailed Answers | Correct
Solutions | Already Passed A+ Graded
SECTION 1: NEUROLOGICAL EMERGENCIES — INCREASED ICP & TRAUMATIC BRAIN INJURY (Questions
1–40)
1. A patient is admitted with a traumatic brain injury (TBI). The nurse assesses a Glasgow Coma Scale
(GCS) score of 12. Two hours later, the patient's pupils are fixed and dilated. What is the priority nursing
action?
A) Reassess the GCS in 15 minutes
B) Document the findings as a normal progression
C) Administer Mannitol as prescribed
D) Lower the head of the bed to 0 degrees
Correct Answer: C
Rationale: A GCS drop coupled with pupillary changes (fixed/dilated) indicates increased intracranial
pressure (ICP) and potential uncal herniation. Mannitol is an osmotic diuretic used to reduce cerebral
edema. Lowering the head of bed (HOB) would increase ICP. This is a medical emergency requiring
immediate intervention.
2. The nurse is caring for a patient at risk for increased ICP. Which positioning intervention is most
appropriate?
A) Supine with head of bed flat to promote perfusion
B) Lateral position with head turned to the side
C) SemiFowler's (30–45 degrees) with head maintained in a midline neutral position
D) Trendelenburg position to enhance venous return
,Correct Answer: C
Rationale: SemiFowler's positioning promotes venous drainage from the brain, reducing ICP. Keeping
the head in a midline neutral position prevents jugular compression, which would impede outflow and
raise ICP.
3. A patient with a closed head injury suddenly develops a widened pulse pressure, bradycardia, and
irregular respirations. The nurse recognizes this as:
A) Neurogenic shock
B) Cushing's Triad
C) Spinal shock
D) Autonomic Dysreflexia
Correct Answer: B
Rationale: Cushing's Triad (hypertension with widened pulse pressure, bradycardia, and irregular
respirations) is a late, ominous sign of increased ICP indicating brainstem compression. It requires
immediate intervention to prevent herniation.
4. The nurse is assessing a patient who sustained a head injury. Initially, the patient was decorticate.
Now, the patient extends the upper and lower extremities in response to painful stimuli. What does this
change indicate?
A) Improved neurological status
B) Development of a spinal cord injury
C) Worsening ICP and brainstem involvement
D) A normal response to painful stimuli
Correct Answer: C
,Rationale: Decorticate posturing (flexion) indicates damage to the cerebral hemispheres. Progression to
decerebrate posturing (extension) indicates deterioration and damage to the midbrain/brainstem. This
is a sign of worsening ICP.
5. The nurse caring for a client with head injury would recognize which assessment findings as early
signs of increased ICP?
A) Kussmaul's breathing and weakness in one extremity
B) Bradycardia and hypertension
C) Fixed and dilated pupils
D) Decerebrate posturing
Correct Answer: A
Rationale: Kussmaul's breathing (deep, rapid breathing) and unilateral weakness are early signs of
increased ICP.
6. A patient with a TBI has a urine output of 300 mL/hr for 2 consecutive hours. What does the nurse
suspect?
A) Normal urine output
B) Diabetes Insipidus
C) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
D) Acute kidney injury
Correct Answer: B
Rationale: TBI can damage the pituitary gland, leading to Diabetes Insipidus. Signs include polyuria (>250
mL/hr), low specific gravity, high serum sodium, and dehydration.
, 7. The nurse is caring for a client with a head injury. Which situation needs intervention by the nurse?
A) The client's spouse turns on the TV for 1 hour in the afternoon and 3 hours in the evening
B) The client is positioned with HOB elevated 30 degrees
C) The client's room is kept dim and quiet
D) The client is suctioned only when necessary
Correct Answer: A
Rationale: In a client with head injury, ICP increases with external stimuli. Environmental stimulation
should be reduced to decrease oxygen consumption and prevent seizures.
8. The critical care nurse is caring for a client with a head injury who is responsive to painful stimuli and
assumes decorticate posturing. Two hours later, which data would warrant immediate intervention?
A) The client extends the upper and lower extremities in response to painful stimuli
B) The client withdraws from painful stimuli
C) The client opens eyes spontaneously
D) The client follows commands
Correct Answer: A
Rationale: Extension of the upper and lower extremities is decerebrate posturing, which indicates the
client's ICP is increasing.
9. The nurse is caring for a client in the ED. Which client should the nurse assess first?
A) A client with a epidural hematoma
B) A client with a simple fracture
C) A client with a sprained ankle
200 Practice Questions & Detailed Answers | Correct
Solutions | Already Passed A+ Graded
SECTION 1: NEUROLOGICAL EMERGENCIES — INCREASED ICP & TRAUMATIC BRAIN INJURY (Questions
1–40)
1. A patient is admitted with a traumatic brain injury (TBI). The nurse assesses a Glasgow Coma Scale
(GCS) score of 12. Two hours later, the patient's pupils are fixed and dilated. What is the priority nursing
action?
A) Reassess the GCS in 15 minutes
B) Document the findings as a normal progression
C) Administer Mannitol as prescribed
D) Lower the head of the bed to 0 degrees
Correct Answer: C
Rationale: A GCS drop coupled with pupillary changes (fixed/dilated) indicates increased intracranial
pressure (ICP) and potential uncal herniation. Mannitol is an osmotic diuretic used to reduce cerebral
edema. Lowering the head of bed (HOB) would increase ICP. This is a medical emergency requiring
immediate intervention.
2. The nurse is caring for a patient at risk for increased ICP. Which positioning intervention is most
appropriate?
A) Supine with head of bed flat to promote perfusion
B) Lateral position with head turned to the side
C) SemiFowler's (30–45 degrees) with head maintained in a midline neutral position
D) Trendelenburg position to enhance venous return
,Correct Answer: C
Rationale: SemiFowler's positioning promotes venous drainage from the brain, reducing ICP. Keeping
the head in a midline neutral position prevents jugular compression, which would impede outflow and
raise ICP.
3. A patient with a closed head injury suddenly develops a widened pulse pressure, bradycardia, and
irregular respirations. The nurse recognizes this as:
A) Neurogenic shock
B) Cushing's Triad
C) Spinal shock
D) Autonomic Dysreflexia
Correct Answer: B
Rationale: Cushing's Triad (hypertension with widened pulse pressure, bradycardia, and irregular
respirations) is a late, ominous sign of increased ICP indicating brainstem compression. It requires
immediate intervention to prevent herniation.
4. The nurse is assessing a patient who sustained a head injury. Initially, the patient was decorticate.
Now, the patient extends the upper and lower extremities in response to painful stimuli. What does this
change indicate?
A) Improved neurological status
B) Development of a spinal cord injury
C) Worsening ICP and brainstem involvement
D) A normal response to painful stimuli
Correct Answer: C
,Rationale: Decorticate posturing (flexion) indicates damage to the cerebral hemispheres. Progression to
decerebrate posturing (extension) indicates deterioration and damage to the midbrain/brainstem. This
is a sign of worsening ICP.
5. The nurse caring for a client with head injury would recognize which assessment findings as early
signs of increased ICP?
A) Kussmaul's breathing and weakness in one extremity
B) Bradycardia and hypertension
C) Fixed and dilated pupils
D) Decerebrate posturing
Correct Answer: A
Rationale: Kussmaul's breathing (deep, rapid breathing) and unilateral weakness are early signs of
increased ICP.
6. A patient with a TBI has a urine output of 300 mL/hr for 2 consecutive hours. What does the nurse
suspect?
A) Normal urine output
B) Diabetes Insipidus
C) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
D) Acute kidney injury
Correct Answer: B
Rationale: TBI can damage the pituitary gland, leading to Diabetes Insipidus. Signs include polyuria (>250
mL/hr), low specific gravity, high serum sodium, and dehydration.
, 7. The nurse is caring for a client with a head injury. Which situation needs intervention by the nurse?
A) The client's spouse turns on the TV for 1 hour in the afternoon and 3 hours in the evening
B) The client is positioned with HOB elevated 30 degrees
C) The client's room is kept dim and quiet
D) The client is suctioned only when necessary
Correct Answer: A
Rationale: In a client with head injury, ICP increases with external stimuli. Environmental stimulation
should be reduced to decrease oxygen consumption and prevent seizures.
8. The critical care nurse is caring for a client with a head injury who is responsive to painful stimuli and
assumes decorticate posturing. Two hours later, which data would warrant immediate intervention?
A) The client extends the upper and lower extremities in response to painful stimuli
B) The client withdraws from painful stimuli
C) The client opens eyes spontaneously
D) The client follows commands
Correct Answer: A
Rationale: Extension of the upper and lower extremities is decerebrate posturing, which indicates the
client's ICP is increasing.
9. The nurse is caring for a client in the ED. Which client should the nurse assess first?
A) A client with a epidural hematoma
B) A client with a simple fracture
C) A client with a sprained ankle
