,NUR 209 Exam 4 | Medical - Surgical Nursing II (2026) Actual
Q&A PDF | Fortis College
1. Which assessment finding is most characteristic of increased intracranial
pressure?
A) Decreased level of consciousness
B) Increased deep tendon reflexes
C) Pinpoint pupils
D) Hyperactive bowel sounds
Correct Answer: Decreased level of consciousness
Rationale: A decreased level of consciousness is the earliest and most reliable
indicator of increasing intracranial pressure. As ICP rises, cerebral perfusion
decreases, leading to altered mental status. Pinpoint pupils suggest pontine injury
or opioid toxicity, wh ile increased reflexes and hyperactive bowel sounds are not
typically associated with rising ICP.
2. A patient with a traumatic brain injury has a blood pressure of 154/68 mm Hg,
pulse of 56 beats/min, and respirations of 12 breaths/min. Which condition does the
nurse recognize?
A) Neurogenic shock
B) Cushing's triad
C) Septic shock
D) Autonomic dysreflexia
Correct Answer: Cushing's triad
,Rationale: Cushing's triad consists of systolic hypertension with widened pulse
pressure, bradycardia, and irregular respirations. It is a late sign of increased
intracranial pressure indicating brainstem compression and impending herniation.
This finding requires i mmediate intervention and notification of the provider.
3. Which action is priority for a patient with a suspected cervical spine injury?
A) Assess for pain using a numeric rating scale
B) Maintain spinal immobilization with a cervical collar
C) Administer corticosteroids intravenously
D) Obtain a chest X - ray
Correct Answer: Maintain spinal immobilization with a cervical collar
Rationale: Maintaining spinal immobilization prevents further injury to the spinal
cord, which can result in permanent paralysis or death. Pain assessment,
corticosteroids, and imaging are important but secondary to preventing additional
spinal cord damage. Spinal p recautions must remain in place until injury is ruled
out.
4. What is the most common trigger for autonomic dysreflexia in a patient with a
spinal cord injury above T6?
A) Distended bladder
B) Cold environment
C) Elevated blood glucose
D) Deep tendon reflex stimulation
Correct Answer: Distended bladder
, Rationale: Autonomic dysreflexia is most commonly triggered by bladder
distension or a blocked urinary catheter. Other triggers include fecal impaction, skin
irritation, and tight clothing. This condition causes severe hypertension and requires
immediate interventio n to identify and remove the noxious stimulus.
5. Which finding indicates neurogenic shock in a patient with a spinal cord injury?
A) Hypertension and tachycardia
B) Hypotension and bradycardia
C) Hypertension and bradycardia
D) Hypotension and tachycardia
Correct Answer: Hypotension and bradycardia
Rationale: Neurogenic shock results from loss of sympathetic tone, causing
vasodilation, hypotension, and bradycardia. This differs from hypovolemic shock,
which presents with tachycardia. Treatment includes fluid resuscitation,
vasopressors, and atropine for sympto matic bradycardia.
6. A patient with a basilar skull fracture has clear fluid leaking from the nose. Which
action should the nurse take?
A) Pack the nose with gauze
B) Suction the nose gently
C) Check the drainage for glucose content
D) Have the patient blow the nose
Correct Answer: Check the drainage for glucose content
Q&A PDF | Fortis College
1. Which assessment finding is most characteristic of increased intracranial
pressure?
A) Decreased level of consciousness
B) Increased deep tendon reflexes
C) Pinpoint pupils
D) Hyperactive bowel sounds
Correct Answer: Decreased level of consciousness
Rationale: A decreased level of consciousness is the earliest and most reliable
indicator of increasing intracranial pressure. As ICP rises, cerebral perfusion
decreases, leading to altered mental status. Pinpoint pupils suggest pontine injury
or opioid toxicity, wh ile increased reflexes and hyperactive bowel sounds are not
typically associated with rising ICP.
2. A patient with a traumatic brain injury has a blood pressure of 154/68 mm Hg,
pulse of 56 beats/min, and respirations of 12 breaths/min. Which condition does the
nurse recognize?
A) Neurogenic shock
B) Cushing's triad
C) Septic shock
D) Autonomic dysreflexia
Correct Answer: Cushing's triad
,Rationale: Cushing's triad consists of systolic hypertension with widened pulse
pressure, bradycardia, and irregular respirations. It is a late sign of increased
intracranial pressure indicating brainstem compression and impending herniation.
This finding requires i mmediate intervention and notification of the provider.
3. Which action is priority for a patient with a suspected cervical spine injury?
A) Assess for pain using a numeric rating scale
B) Maintain spinal immobilization with a cervical collar
C) Administer corticosteroids intravenously
D) Obtain a chest X - ray
Correct Answer: Maintain spinal immobilization with a cervical collar
Rationale: Maintaining spinal immobilization prevents further injury to the spinal
cord, which can result in permanent paralysis or death. Pain assessment,
corticosteroids, and imaging are important but secondary to preventing additional
spinal cord damage. Spinal p recautions must remain in place until injury is ruled
out.
4. What is the most common trigger for autonomic dysreflexia in a patient with a
spinal cord injury above T6?
A) Distended bladder
B) Cold environment
C) Elevated blood glucose
D) Deep tendon reflex stimulation
Correct Answer: Distended bladder
, Rationale: Autonomic dysreflexia is most commonly triggered by bladder
distension or a blocked urinary catheter. Other triggers include fecal impaction, skin
irritation, and tight clothing. This condition causes severe hypertension and requires
immediate interventio n to identify and remove the noxious stimulus.
5. Which finding indicates neurogenic shock in a patient with a spinal cord injury?
A) Hypertension and tachycardia
B) Hypotension and bradycardia
C) Hypertension and bradycardia
D) Hypotension and tachycardia
Correct Answer: Hypotension and bradycardia
Rationale: Neurogenic shock results from loss of sympathetic tone, causing
vasodilation, hypotension, and bradycardia. This differs from hypovolemic shock,
which presents with tachycardia. Treatment includes fluid resuscitation,
vasopressors, and atropine for sympto matic bradycardia.
6. A patient with a basilar skull fracture has clear fluid leaking from the nose. Which
action should the nurse take?
A) Pack the nose with gauze
B) Suction the nose gently
C) Check the drainage for glucose content
D) Have the patient blow the nose
Correct Answer: Check the drainage for glucose content
