NUR209 – Medical-Surgical Nursing II
Exam 4 Questions with Answers– Fortis College|Pass Guaranteed
1. A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 7.
The nurse recognizes this indicates:
A. Mild brain injury
B. Moderate brain injury
C. Severe brain injury requiring airway protection
D. Normal neurological function
Answer: C
Rationale: A GCS score of 8 or less is classified as severe brain injury and indicates the
patient cannot protect their own airway; intubation is typically required to prevent
aspiration and ensure adequate oxygenation.
2. Which early sign of increased intracranial pressure (ICP) should the nurse assess for
first, as it precedes other changes?
A. Cushing's triad (bradycardia, hypertension, irregular respirations)
B. Change in level of consciousness
C. Fixed and dilated pupils
D. Decorticate posturing
Answer: B
Rationale: A change in level of consciousness (restlessness, confusion, lethargy) is the
earliest and most sensitive indicator of increased ICP, occurring before pupillary changes,
posturing, or Cushing's triad, which are late signs.
3. Cushing's triad, a late and ominous sign of increased ICP, consists of which three
findings?
A. Tachycardia, hypotension, tachypnea
B. Bradycardia, hypertension (widening pulse pressure), and irregular respirations
C. Hypotension, bradypnea, fever
D. Tachycardia, hypertension, hyperventilation
Answer: B
Rationale: Cushing's triad—bradycardia, hypertension with widening pulse pressure, and
irregular respirations—reflects the brain's attempt to maintain cerebral perfusion
against rising ICP and signals impending herniation, a neurological emergency.
,4. Which nursing intervention helps reduce intracranial pressure in a patient with a
head injury?
A. Keep the head of bed flat (0 degrees)
B. Elevate the head of the bed to 30 degrees and maintain the head in a neutral,
midline position
C. Encourage the Valsalva maneuver
D. Cluster all nursing care into one session with no rest periods
Answer: B
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from
the brain, and keeping the head midline (avoiding neck flexion or rotation) prevents
jugular venous compression, both of which help reduce ICP.
5. A patient with a basilar skull fracture develops clear fluid drainage from the nose.
Which nursing action confirms this is cerebrospinal fluid (CSF) rather than mucus?
A. Test the drainage with a urine dipstick for protein only
B. Test the fluid for glucose (positive in CSF) or observe for a "halo" or "ring" sign on
gauze/linen
C. Have the patient blow their nose forcefully to check for pain
D. No testing is necessary; assume it is mucus
Answer: B
Rationale: CSF contains glucose (unlike typical nasal mucus), so a positive glucose test
(via dipstick, with limitations) or the classic "halo sign" (a clear ring surrounding a blood
spot when dripped onto gauze or linen) helps identify CSF leakage, indicating a dural
tear.
6. A patient with suspected CSF rhinorrhea should be taught to avoid which action to
reduce the risk of meningitis and worsening the leak?
A. Blowing the nose, sneezing forcefully, or straining, and nasal suctioning/packing
B. Sitting upright
C. Drinking fluids
D. Speaking normally
Answer: A
Rationale: Blowing the nose, forceful sneezing, straining, and nasal suctioning or
packing increase the risk of introducing pathogens through the dural tear (risking
meningitis) and can worsen the CSF leak; patients are taught to avoid these actions.
,7. Which finding on pupillary assessment is most concerning for uncal (transtentorial)
herniation in a patient with a head injury?
A. Bilateral pupils equal and reactive to light
B. A unilateral, fixed, and dilated pupil on the side of the injury
C. Pinpoint pupils bilaterally
D. Sluggish but equal pupillary response bilaterally
Answer: B
Rationale: A unilateral fixed and dilated pupil (often called a "blown pupil") results from
compression of the oculomotor nerve (CN III) as the uncus herniates through the
tentorium, indicating a neurosurgical emergency requiring immediate intervention.
8. A patient with increased ICP is prescribed mannitol. The nurse understands this
medication works by:
A. Increasing cerebral blood volume
B. Creating an osmotic gradient that draws fluid out of brain tissue into the
vasculature, reducing cerebral edema
C. Causing cerebral vasodilation
D. Directly lowering blood pressure with no effect on brain fluid
Answer: B
Rationale: Mannitol is an osmotic diuretic that increases plasma osmolality, drawing
water out of brain tissue and into the vascular space, thereby reducing cerebral edema
and intracranial pressure; it is then excreted by the kidneys.
9. While administering mannitol, the nurse should monitor for which potential
complication?
A. Hypervolemia and hyponatremia only
B. Dehydration, hypovolemia, and electrolyte imbalances due to its diuretic effect
C. Hypoglycemia
D. Bradycardia as the primary concern
Answer: B
Rationale: Because mannitol promotes significant diuresis, patients require close
monitoring of fluid status, serum osmolality, and electrolytes (particularly sodium and
potassium), as excessive fluid loss can cause dehydration, hypovolemia, and electrolyte
imbalance.
10. A patient with a decorticate posturing response to painful stimuli exhibits which
position?
, A. Arms extended, wrists pronated, legs extended and internally rotated
B. Arms flexed toward the core, wrists flexed, legs extended
C. Flaccid with no movement
D. Normal purposeful withdrawal from pain
Answer: B
Rationale: Decorticate (flexor) posturing involves flexion of the arms toward the body
core with wrist flexion and leg extension, indicating damage above the brainstem
(cerebral hemispheres); it is a less severe finding than decerebrate posturing.
11. Decerebrate posturing, indicating brainstem damage, is characterized by:
A. Flexion of the arms and legs
B. Extension and rigid pronation of the arms and extension of the legs
C. No response to stimuli
D. Purposeful movement toward the stimulus
Answer: B
Rationale: Decerebrate (extensor) posturing involves rigid extension and internal
rotation of the arms with wrist pronation and extension of the legs, indicating more
severe brainstem damage than decorticate posturing and a worsening neurological
status.
12. Which is the target range for cerebral perfusion pressure (CPP) to ensure adequate
brain perfusion in a patient with a head injury?
A. 5-10 mmHg
B. 60-100 mmHg
C. 150-200 mmHg
D. 0-5 mmHg
Answer: B
Rationale: CPP is calculated as mean arterial pressure (MAP) minus intracranial pressure
(ICP); a CPP of 60-100 mmHg is generally targeted to maintain adequate cerebral blood
flow, as levels below 50-60 mmHg risk cerebral ischemia.
13. A patient with increased ICP requires suctioning. Which nursing action minimizes
further ICP elevation during the procedure?
A. Suction for as long as needed without limit
B. Hyperoxygenate before and after suctioning, and limit suction passes to less than
10-15 seconds
C. Suction repeatedly without rest periods
Exam 4 Questions with Answers– Fortis College|Pass Guaranteed
1. A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 7.
The nurse recognizes this indicates:
A. Mild brain injury
B. Moderate brain injury
C. Severe brain injury requiring airway protection
D. Normal neurological function
Answer: C
Rationale: A GCS score of 8 or less is classified as severe brain injury and indicates the
patient cannot protect their own airway; intubation is typically required to prevent
aspiration and ensure adequate oxygenation.
2. Which early sign of increased intracranial pressure (ICP) should the nurse assess for
first, as it precedes other changes?
A. Cushing's triad (bradycardia, hypertension, irregular respirations)
B. Change in level of consciousness
C. Fixed and dilated pupils
D. Decorticate posturing
Answer: B
Rationale: A change in level of consciousness (restlessness, confusion, lethargy) is the
earliest and most sensitive indicator of increased ICP, occurring before pupillary changes,
posturing, or Cushing's triad, which are late signs.
3. Cushing's triad, a late and ominous sign of increased ICP, consists of which three
findings?
A. Tachycardia, hypotension, tachypnea
B. Bradycardia, hypertension (widening pulse pressure), and irregular respirations
C. Hypotension, bradypnea, fever
D. Tachycardia, hypertension, hyperventilation
Answer: B
Rationale: Cushing's triad—bradycardia, hypertension with widening pulse pressure, and
irregular respirations—reflects the brain's attempt to maintain cerebral perfusion
against rising ICP and signals impending herniation, a neurological emergency.
,4. Which nursing intervention helps reduce intracranial pressure in a patient with a
head injury?
A. Keep the head of bed flat (0 degrees)
B. Elevate the head of the bed to 30 degrees and maintain the head in a neutral,
midline position
C. Encourage the Valsalva maneuver
D. Cluster all nursing care into one session with no rest periods
Answer: B
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from
the brain, and keeping the head midline (avoiding neck flexion or rotation) prevents
jugular venous compression, both of which help reduce ICP.
5. A patient with a basilar skull fracture develops clear fluid drainage from the nose.
Which nursing action confirms this is cerebrospinal fluid (CSF) rather than mucus?
A. Test the drainage with a urine dipstick for protein only
B. Test the fluid for glucose (positive in CSF) or observe for a "halo" or "ring" sign on
gauze/linen
C. Have the patient blow their nose forcefully to check for pain
D. No testing is necessary; assume it is mucus
Answer: B
Rationale: CSF contains glucose (unlike typical nasal mucus), so a positive glucose test
(via dipstick, with limitations) or the classic "halo sign" (a clear ring surrounding a blood
spot when dripped onto gauze or linen) helps identify CSF leakage, indicating a dural
tear.
6. A patient with suspected CSF rhinorrhea should be taught to avoid which action to
reduce the risk of meningitis and worsening the leak?
A. Blowing the nose, sneezing forcefully, or straining, and nasal suctioning/packing
B. Sitting upright
C. Drinking fluids
D. Speaking normally
Answer: A
Rationale: Blowing the nose, forceful sneezing, straining, and nasal suctioning or
packing increase the risk of introducing pathogens through the dural tear (risking
meningitis) and can worsen the CSF leak; patients are taught to avoid these actions.
,7. Which finding on pupillary assessment is most concerning for uncal (transtentorial)
herniation in a patient with a head injury?
A. Bilateral pupils equal and reactive to light
B. A unilateral, fixed, and dilated pupil on the side of the injury
C. Pinpoint pupils bilaterally
D. Sluggish but equal pupillary response bilaterally
Answer: B
Rationale: A unilateral fixed and dilated pupil (often called a "blown pupil") results from
compression of the oculomotor nerve (CN III) as the uncus herniates through the
tentorium, indicating a neurosurgical emergency requiring immediate intervention.
8. A patient with increased ICP is prescribed mannitol. The nurse understands this
medication works by:
A. Increasing cerebral blood volume
B. Creating an osmotic gradient that draws fluid out of brain tissue into the
vasculature, reducing cerebral edema
C. Causing cerebral vasodilation
D. Directly lowering blood pressure with no effect on brain fluid
Answer: B
Rationale: Mannitol is an osmotic diuretic that increases plasma osmolality, drawing
water out of brain tissue and into the vascular space, thereby reducing cerebral edema
and intracranial pressure; it is then excreted by the kidneys.
9. While administering mannitol, the nurse should monitor for which potential
complication?
A. Hypervolemia and hyponatremia only
B. Dehydration, hypovolemia, and electrolyte imbalances due to its diuretic effect
C. Hypoglycemia
D. Bradycardia as the primary concern
Answer: B
Rationale: Because mannitol promotes significant diuresis, patients require close
monitoring of fluid status, serum osmolality, and electrolytes (particularly sodium and
potassium), as excessive fluid loss can cause dehydration, hypovolemia, and electrolyte
imbalance.
10. A patient with a decorticate posturing response to painful stimuli exhibits which
position?
, A. Arms extended, wrists pronated, legs extended and internally rotated
B. Arms flexed toward the core, wrists flexed, legs extended
C. Flaccid with no movement
D. Normal purposeful withdrawal from pain
Answer: B
Rationale: Decorticate (flexor) posturing involves flexion of the arms toward the body
core with wrist flexion and leg extension, indicating damage above the brainstem
(cerebral hemispheres); it is a less severe finding than decerebrate posturing.
11. Decerebrate posturing, indicating brainstem damage, is characterized by:
A. Flexion of the arms and legs
B. Extension and rigid pronation of the arms and extension of the legs
C. No response to stimuli
D. Purposeful movement toward the stimulus
Answer: B
Rationale: Decerebrate (extensor) posturing involves rigid extension and internal
rotation of the arms with wrist pronation and extension of the legs, indicating more
severe brainstem damage than decorticate posturing and a worsening neurological
status.
12. Which is the target range for cerebral perfusion pressure (CPP) to ensure adequate
brain perfusion in a patient with a head injury?
A. 5-10 mmHg
B. 60-100 mmHg
C. 150-200 mmHg
D. 0-5 mmHg
Answer: B
Rationale: CPP is calculated as mean arterial pressure (MAP) minus intracranial pressure
(ICP); a CPP of 60-100 mmHg is generally targeted to maintain adequate cerebral blood
flow, as levels below 50-60 mmHg risk cerebral ischemia.
13. A patient with increased ICP requires suctioning. Which nursing action minimizes
further ICP elevation during the procedure?
A. Suction for as long as needed without limit
B. Hyperoxygenate before and after suctioning, and limit suction passes to less than
10-15 seconds
C. Suction repeatedly without rest periods
