NUR 265 Exam 3 – Galen College of
Nursing Medical-Surgical Nursing
Updated
This comprehensive review contains 80 exam-style
questions designed to prepare you for the NUR 265
Exam 3 at Galen College of Nursing. Questions are
based on the medical-surgical nursing curriculum
with verified answers and detailed rationales.
SECTION 1: NEUROLOGICAL DISORDERS &
HEAD INJURY
(Questions 1-35)
1
,1. A client with a traumatic brain injury (TBI) has a
Glasgow Coma Scale (GCS) score of 6. What is the
priority nursing action?
- A) Administer IV fluids
- B) Prepare for intubation and mechanical
ventilation
- C) Apply a cervical collar only
- D) Obtain a CT scan immediately
Answer: B) Prepare for intubation and mechanical
ventilation
Rationale: A GCS ≤ 8 indicates a severe brain injury
with an inability to protect the airway. Securing the
airway via intubation is the priority per the ABCs
(Airway, Breathing, Circulation). While imaging is
essential, airway protection comes first to prevent
hypoxia and secondary brain injury .
2
,2. A client with a C5 spinal cord injury develops a
severe headache, hypertension (BP 210/110 mm
Hg), and bradycardia. What condition is suspected?
- A) Spinal shock
- B) Autonomic dysreflexia
- C) Neurogenic shock
- D) Increased intracranial pressure
Answer: B) Autonomic dysreflexia
Rationale: Autonomic dysreflexia occurs in injuries
at T6 or above due to an unopposed sympathetic
response to noxious stimuli (e.g., a full bladder).
Symptoms include severe hypertension, bradycardia,
headache, and flushing above the level of the lesion.
It is a medical emergency requiring immediate
intervention (sit upright, check for bladder/bowel
distension) .
3
, 3. The charge nurse is observing a newly hired nurse
care for a client who sustained a closed head injury,
is receiving mechanical ventilation, and is at risk for
developing increased intracranial pressure (ICP).
Which action by the newly hired nurse requires
intervention by the charge nurse?
- A) Using the bag-valve mask on the client when
the low-pressure alarm sounds
- B) Raising the foot of the client's bed
- C) Setting up suction equipment at the bedside
- D) Maintaining the client's head at midline, neutral
position
Answer: B) Raising the foot of the client's bed
Rationale: Raising the foot of the bed can increase
intracranial pressure by decreasing venous return
from the head. The head of the bed should be
elevated 30-45 degrees to promote venous drainage
and reduce ICP. The head should be maintained in a
midline, neutral position to prevent jugular vein
compression .
4
Nursing Medical-Surgical Nursing
Updated
This comprehensive review contains 80 exam-style
questions designed to prepare you for the NUR 265
Exam 3 at Galen College of Nursing. Questions are
based on the medical-surgical nursing curriculum
with verified answers and detailed rationales.
SECTION 1: NEUROLOGICAL DISORDERS &
HEAD INJURY
(Questions 1-35)
1
,1. A client with a traumatic brain injury (TBI) has a
Glasgow Coma Scale (GCS) score of 6. What is the
priority nursing action?
- A) Administer IV fluids
- B) Prepare for intubation and mechanical
ventilation
- C) Apply a cervical collar only
- D) Obtain a CT scan immediately
Answer: B) Prepare for intubation and mechanical
ventilation
Rationale: A GCS ≤ 8 indicates a severe brain injury
with an inability to protect the airway. Securing the
airway via intubation is the priority per the ABCs
(Airway, Breathing, Circulation). While imaging is
essential, airway protection comes first to prevent
hypoxia and secondary brain injury .
2
,2. A client with a C5 spinal cord injury develops a
severe headache, hypertension (BP 210/110 mm
Hg), and bradycardia. What condition is suspected?
- A) Spinal shock
- B) Autonomic dysreflexia
- C) Neurogenic shock
- D) Increased intracranial pressure
Answer: B) Autonomic dysreflexia
Rationale: Autonomic dysreflexia occurs in injuries
at T6 or above due to an unopposed sympathetic
response to noxious stimuli (e.g., a full bladder).
Symptoms include severe hypertension, bradycardia,
headache, and flushing above the level of the lesion.
It is a medical emergency requiring immediate
intervention (sit upright, check for bladder/bowel
distension) .
3
, 3. The charge nurse is observing a newly hired nurse
care for a client who sustained a closed head injury,
is receiving mechanical ventilation, and is at risk for
developing increased intracranial pressure (ICP).
Which action by the newly hired nurse requires
intervention by the charge nurse?
- A) Using the bag-valve mask on the client when
the low-pressure alarm sounds
- B) Raising the foot of the client's bed
- C) Setting up suction equipment at the bedside
- D) Maintaining the client's head at midline, neutral
position
Answer: B) Raising the foot of the client's bed
Rationale: Raising the foot of the bed can increase
intracranial pressure by decreasing venous return
from the head. The head of the bed should be
elevated 30-45 degrees to promote venous drainage
and reduce ICP. The head should be maintained in a
midline, neutral position to prevent jugular vein
compression .
4
