NUR 2755 – Multidimensional Care IV
(MDC 4) Final Exam Questions with
Answers| Rasmussen University|
Updated| Pass Guaranteed
1. A patient with a traumatic brain injury becomes increasingly difficult to arouse. What
should the nurse do first?
A. Allow the patient to sleep
B. Assess airway, breathing, and neurological status
C. Offer oral fluids
D. Begin discharge teaching
Correct Answer: B. Assess airway, breathing, and neurological status
Rationale: A decreasing level of consciousness can indicate neurological deterioration and can
compromise airway protection. ABC assessment and immediate neurological reassessment are
priorities.
2. Which finding is most concerning for increased intracranial pressure?
A. Mild fatigue
B. Decreasing level of consciousness
C. Increased appetite
D. Stable orientation
Correct Answer: B. Decreasing level of consciousness
Rationale: A declining level of consciousness is an important indicator of worsening neurological
function and possible increased ICP.
3. A patient with a head injury develops hypertension, bradycardia, and irregular respirations.
What does the nurse suspect?
A. Hypovolemic shock
B. Cushing response
,C. Septic shock
D. Anaphylaxis
Correct Answer: B. Cushing response
Rationale: Hypertension, bradycardia, and abnormal respirations constitute the classic Cushing
response and can indicate significantly increased intracranial pressure.
4. Which position is generally appropriate for a patient with increased ICP?
A. Head elevated with neck in neutral alignment
B. Trendelenburg
C. Flat with hips sharply flexed
D. Prone with the head turned
Correct Answer: A. Head elevated with neck in neutral alignment
Rationale: Appropriate head elevation and neutral alignment promote cerebral venous drainage
and can help limit increases in ICP.
5. Which intervention should the nurse avoid in a patient with increased ICP?
A. Maintaining a quiet environment
B. Maintaining neutral neck alignment
C. Encouraging prolonged coughing and straining
D. Performing serial neurological assessments
Correct Answer: C. Encouraging prolonged coughing and straining
Rationale: Coughing and straining can increase intrathoracic pressure and consequently raise
intracranial pressure.
6. A patient with traumatic brain injury suddenly develops unequal pupils. What is the
priority?
A. Reassess the patient and immediately escalate the change
B. Document it at the end of the shift
C. Give oral fluids
D. Encourage ambulation
,Correct Answer: A. Reassess the patient and immediately escalate the change
Rationale: New anisocoria can indicate serious intracranial deterioration and requires
immediate evaluation.
7. Which finding may indicate a basilar skull fracture?
A. Clear drainage from the ear
B. Bilateral ankle edema
C. Productive cough
D. Abdominal tenderness
Correct Answer: A. Clear drainage from the ear
Rationale: Clear drainage from the nose or ear after head trauma may represent cerebrospinal
fluid leakage.
8. Which action should the nurse avoid if CSF leakage is suspected?
A. Monitoring neurological status
B. Reporting the finding
C. Tightly packing the ear or nose
D. Monitoring vital signs
Correct Answer: C. Tightly packing the ear or nose
Rationale: Tight packing may interfere with drainage and can introduce infection or increase
pressure.
9. A patient with TBI becomes restless and agitated. What should the nurse assess first?
A. Oxygenation and neurological status
B. Dietary preference
C. Sleep schedule
D. Bowel habits
Correct Answer: A. Oxygenation and neurological status
Rationale: Restlessness can be an early sign of hypoxemia, pain, increased ICP, or neurological
deterioration.
, 10. Which intervention is particularly important to prevent secondary brain injury?
A. Prevent hypoxemia and hypotension
B. Encourage prolonged bed rest without repositioning
C. Maintain dehydration
D. Avoid neurological assessments
Correct Answer: A. Prevent hypoxemia and hypotension
Rationale: Adequate oxygenation and cerebral perfusion are critical after an initial brain injury.
11. A patient with a cervical spinal cord injury has shallow respirations. What is the priority?
A. Assess respiratory function immediately
B. Assess bowel sounds
C. Offer food
D. Encourage walking
Correct Answer: A. Assess respiratory function immediately
Rationale: High spinal cord injuries can impair respiratory muscle function and rapidly lead to
respiratory failure.
12. Which finding is characteristic of neurogenic shock?
A. Bradycardia and hypotension
B. Tachycardia and hypertension
C. Fever and tachycardia
D. Severe hypertension
Correct Answer: A. Bradycardia and hypotension
Rationale: Loss of sympathetic vascular tone causes vasodilation and hypotension, often
accompanied by bradycardia.
13. A patient with a T4 spinal cord injury suddenly develops severe headache, flushing, and
BP 210/110 mm Hg. What should the nurse do first?
(MDC 4) Final Exam Questions with
Answers| Rasmussen University|
Updated| Pass Guaranteed
1. A patient with a traumatic brain injury becomes increasingly difficult to arouse. What
should the nurse do first?
A. Allow the patient to sleep
B. Assess airway, breathing, and neurological status
C. Offer oral fluids
D. Begin discharge teaching
Correct Answer: B. Assess airway, breathing, and neurological status
Rationale: A decreasing level of consciousness can indicate neurological deterioration and can
compromise airway protection. ABC assessment and immediate neurological reassessment are
priorities.
2. Which finding is most concerning for increased intracranial pressure?
A. Mild fatigue
B. Decreasing level of consciousness
C. Increased appetite
D. Stable orientation
Correct Answer: B. Decreasing level of consciousness
Rationale: A declining level of consciousness is an important indicator of worsening neurological
function and possible increased ICP.
3. A patient with a head injury develops hypertension, bradycardia, and irregular respirations.
What does the nurse suspect?
A. Hypovolemic shock
B. Cushing response
,C. Septic shock
D. Anaphylaxis
Correct Answer: B. Cushing response
Rationale: Hypertension, bradycardia, and abnormal respirations constitute the classic Cushing
response and can indicate significantly increased intracranial pressure.
4. Which position is generally appropriate for a patient with increased ICP?
A. Head elevated with neck in neutral alignment
B. Trendelenburg
C. Flat with hips sharply flexed
D. Prone with the head turned
Correct Answer: A. Head elevated with neck in neutral alignment
Rationale: Appropriate head elevation and neutral alignment promote cerebral venous drainage
and can help limit increases in ICP.
5. Which intervention should the nurse avoid in a patient with increased ICP?
A. Maintaining a quiet environment
B. Maintaining neutral neck alignment
C. Encouraging prolonged coughing and straining
D. Performing serial neurological assessments
Correct Answer: C. Encouraging prolonged coughing and straining
Rationale: Coughing and straining can increase intrathoracic pressure and consequently raise
intracranial pressure.
6. A patient with traumatic brain injury suddenly develops unequal pupils. What is the
priority?
A. Reassess the patient and immediately escalate the change
B. Document it at the end of the shift
C. Give oral fluids
D. Encourage ambulation
,Correct Answer: A. Reassess the patient and immediately escalate the change
Rationale: New anisocoria can indicate serious intracranial deterioration and requires
immediate evaluation.
7. Which finding may indicate a basilar skull fracture?
A. Clear drainage from the ear
B. Bilateral ankle edema
C. Productive cough
D. Abdominal tenderness
Correct Answer: A. Clear drainage from the ear
Rationale: Clear drainage from the nose or ear after head trauma may represent cerebrospinal
fluid leakage.
8. Which action should the nurse avoid if CSF leakage is suspected?
A. Monitoring neurological status
B. Reporting the finding
C. Tightly packing the ear or nose
D. Monitoring vital signs
Correct Answer: C. Tightly packing the ear or nose
Rationale: Tight packing may interfere with drainage and can introduce infection or increase
pressure.
9. A patient with TBI becomes restless and agitated. What should the nurse assess first?
A. Oxygenation and neurological status
B. Dietary preference
C. Sleep schedule
D. Bowel habits
Correct Answer: A. Oxygenation and neurological status
Rationale: Restlessness can be an early sign of hypoxemia, pain, increased ICP, or neurological
deterioration.
, 10. Which intervention is particularly important to prevent secondary brain injury?
A. Prevent hypoxemia and hypotension
B. Encourage prolonged bed rest without repositioning
C. Maintain dehydration
D. Avoid neurological assessments
Correct Answer: A. Prevent hypoxemia and hypotension
Rationale: Adequate oxygenation and cerebral perfusion are critical after an initial brain injury.
11. A patient with a cervical spinal cord injury has shallow respirations. What is the priority?
A. Assess respiratory function immediately
B. Assess bowel sounds
C. Offer food
D. Encourage walking
Correct Answer: A. Assess respiratory function immediately
Rationale: High spinal cord injuries can impair respiratory muscle function and rapidly lead to
respiratory failure.
12. Which finding is characteristic of neurogenic shock?
A. Bradycardia and hypotension
B. Tachycardia and hypertension
C. Fever and tachycardia
D. Severe hypertension
Correct Answer: A. Bradycardia and hypotension
Rationale: Loss of sympathetic vascular tone causes vasodilation and hypotension, often
accompanied by bradycardia.
13. A patient with a T4 spinal cord injury suddenly develops severe headache, flushing, and
BP 210/110 mm Hg. What should the nurse do first?
