NUR 265 Exam 4 | NUR 265 Advanced Medical-Surgical
Nursing | Questions and Answers with Rationales
2026/2027 Update
QUESTION 1
A client is admitted to the neurological intensive care unit following a severe
traumatic brain injury. Which clinical manifestation is a classic sign of increasing
intracranial pressure?
A. Hypotension and tachycardia
B. Widening pulse pressure, bradycardia, and irregular respirations
C. Rapid, shallow breathing and warm, flushed skin
D. Normal blood pressure with bounding peripheral pulses
ANSWER: B
RATIONALE: Cushing's triad is a late and ominous sign of increased intracranial
pressure characterized by systolic hypertension with a widening pulse pressure,
bradycardia, and irregular respiratory patterns such as Cheyne-Stokes
respirations.
QUESTION 2
A client with a traumatic brain injury has a mean arterial pressure of 90 mmHg
and an intracranial pressure of 20 mmHg. What is the calculated cerebral
perfusion pressure, and is it within the normal adult range?
A. 70 mmHg, which is within the normal range
B. 50 mmHg, which is below the normal range
C. 110 mmHg, which is above the normal range
D. 40 mmHg, which is below the normal range
ANSWER: A
,RATIONALE: Cerebral perfusion pressure is calculated by subtracting intracranial
pressure from mean arterial pressure (CPP equals MAP minus ICP). Calculation: 90
minus 20 equals 70 mmHg. The normal adult CPP range is 70 to 100 mmHg.
Therefore, 70 mmHg is at the lower limit of normal.
QUESTION 3
Which nursing intervention is crucial for positioning a client with increased
intracranial pressure to optimize cerebral venous drainage?
A. Keep the head of the bed flat at zero degrees
B. Maintain the head of the bed elevated 30 to 45 degrees in neutral midline
alignment
C. Turn the client's head sharply to the side during care
D. Place the client in the Trendelenburg position with feet elevated
ANSWER: B
RATIONALE: Elevating the head of the bed 30 to 45 degrees while keeping the
head and neck in a neutral, midline alignment promotes cerebral venous outflow
through the jugular veins, helping to reduce intracranial pressure.
QUESTION 4
A client with increased intracranial pressure is prescribed mannitol. What is the
primary mechanism of action of this osmotic diuretic?
A. Inhibits sodium reabsorption in the distal renal tubule
B. Draws water from brain tissue into the vascular space by increasing the osmotic
pressure of the glomerular filtrate
C. Blocks aldosterone receptors to promote sodium excretion
D. Dilates cerebral blood vessels to increase regional blood flow
ANSWER: B
RATIONALE: Mannitol is an osmotic diuretic that increases the osmolality of the
glomerular filtrate, drawing water out of the edematous brain tissue and into the
,intravascular space to be excreted by the kidneys, effectively lowering intracranial
pressure.
QUESTION 5
A client with a basilar skull fracture exhibits cerebrospinal fluid rhinorrhea. Which
diagnostic procedure or nursing intervention is strictly contraindicated for this
client?
A. Computed tomography scan of the head
B. Insertion of a nasogastric tube
C. Administration of intravenous antibiotics
D. Application of a sterile loose dressing over the nose
ANSWER: B
RATIONALE: Insertion of a nasogastric tube is strictly contraindicated in clients
with basilar skull fractures and cerebrospinal fluid rhinorrhea because the tube
can inadvertently pass through the fractured cribriform plate into the intracranial
vault.
QUESTION 6
Which clinical manifestation is expected in a client with a spinal cord injury
experiencing spinal shock immediately following trauma?
A. Spasticity, hyperreflexia, and hypertension
B. Complete loss of reflex activity, flaccid paralysis, and sensory loss below the
level of the injury
C. Paroxysmal hypertension and severe throbbing headache
D. Tachycardia and warm, dry skin
ANSWER: B
RATIONALE: Spinal shock is a temporary physiological response occurring
immediately after spinal cord injury, characterized by complete loss of all reflex
activity, flaccid paralysis, and anesthesia below the level of the lesion.
, QUESTION 7
A client with a T6 spinal cord injury develops a severe throbbing headache, nasal
congestion, and paroxysmal hypertension with a blood pressure of 200 over 110
mmHg. What is the immediate priority nursing action?
A. Administer intravenous antihypertensive medication immediately
B. Sit the client upright and check for bladder distension or a kinked catheter
C. Perform a rectal examination for impaction without checking the bladder
D. Place the client in a flat supine position
ANSWER: B
RATIONALE: This client is experiencing autonomic dysreflexia, a medical
emergency triggered by a noxious stimulus below the injury level, most commonly
bladder distension. The immediate nursing actions are to sit the client upright to
lower blood pressure and identify and remove the triggering stimulus.
QUESTION 8
Which clinical sign differentiates neurogenic shock from hypovolemic shock in a
client with acute spinal cord injury?
A. Tachycardia and cool, clammy skin
B. Bradycardia and warm, dry, flushed skin
C. Tachypnea and elevated blood pressure
D. Anxiety and restlessness
ANSWER: B
RATIONALE: Neurogenic shock involves loss of sympathetic nervous system
vasoconstrictor tone, resulting in unopposed parasympathetic activity
characterized by bradycardia, hypotension, and warm, dry skin, unlike
hypovolemic shock which causes tachycardia and cool skin.
QUESTION 9
Nursing | Questions and Answers with Rationales
2026/2027 Update
QUESTION 1
A client is admitted to the neurological intensive care unit following a severe
traumatic brain injury. Which clinical manifestation is a classic sign of increasing
intracranial pressure?
A. Hypotension and tachycardia
B. Widening pulse pressure, bradycardia, and irregular respirations
C. Rapid, shallow breathing and warm, flushed skin
D. Normal blood pressure with bounding peripheral pulses
ANSWER: B
RATIONALE: Cushing's triad is a late and ominous sign of increased intracranial
pressure characterized by systolic hypertension with a widening pulse pressure,
bradycardia, and irregular respiratory patterns such as Cheyne-Stokes
respirations.
QUESTION 2
A client with a traumatic brain injury has a mean arterial pressure of 90 mmHg
and an intracranial pressure of 20 mmHg. What is the calculated cerebral
perfusion pressure, and is it within the normal adult range?
A. 70 mmHg, which is within the normal range
B. 50 mmHg, which is below the normal range
C. 110 mmHg, which is above the normal range
D. 40 mmHg, which is below the normal range
ANSWER: A
,RATIONALE: Cerebral perfusion pressure is calculated by subtracting intracranial
pressure from mean arterial pressure (CPP equals MAP minus ICP). Calculation: 90
minus 20 equals 70 mmHg. The normal adult CPP range is 70 to 100 mmHg.
Therefore, 70 mmHg is at the lower limit of normal.
QUESTION 3
Which nursing intervention is crucial for positioning a client with increased
intracranial pressure to optimize cerebral venous drainage?
A. Keep the head of the bed flat at zero degrees
B. Maintain the head of the bed elevated 30 to 45 degrees in neutral midline
alignment
C. Turn the client's head sharply to the side during care
D. Place the client in the Trendelenburg position with feet elevated
ANSWER: B
RATIONALE: Elevating the head of the bed 30 to 45 degrees while keeping the
head and neck in a neutral, midline alignment promotes cerebral venous outflow
through the jugular veins, helping to reduce intracranial pressure.
QUESTION 4
A client with increased intracranial pressure is prescribed mannitol. What is the
primary mechanism of action of this osmotic diuretic?
A. Inhibits sodium reabsorption in the distal renal tubule
B. Draws water from brain tissue into the vascular space by increasing the osmotic
pressure of the glomerular filtrate
C. Blocks aldosterone receptors to promote sodium excretion
D. Dilates cerebral blood vessels to increase regional blood flow
ANSWER: B
RATIONALE: Mannitol is an osmotic diuretic that increases the osmolality of the
glomerular filtrate, drawing water out of the edematous brain tissue and into the
,intravascular space to be excreted by the kidneys, effectively lowering intracranial
pressure.
QUESTION 5
A client with a basilar skull fracture exhibits cerebrospinal fluid rhinorrhea. Which
diagnostic procedure or nursing intervention is strictly contraindicated for this
client?
A. Computed tomography scan of the head
B. Insertion of a nasogastric tube
C. Administration of intravenous antibiotics
D. Application of a sterile loose dressing over the nose
ANSWER: B
RATIONALE: Insertion of a nasogastric tube is strictly contraindicated in clients
with basilar skull fractures and cerebrospinal fluid rhinorrhea because the tube
can inadvertently pass through the fractured cribriform plate into the intracranial
vault.
QUESTION 6
Which clinical manifestation is expected in a client with a spinal cord injury
experiencing spinal shock immediately following trauma?
A. Spasticity, hyperreflexia, and hypertension
B. Complete loss of reflex activity, flaccid paralysis, and sensory loss below the
level of the injury
C. Paroxysmal hypertension and severe throbbing headache
D. Tachycardia and warm, dry skin
ANSWER: B
RATIONALE: Spinal shock is a temporary physiological response occurring
immediately after spinal cord injury, characterized by complete loss of all reflex
activity, flaccid paralysis, and anesthesia below the level of the lesion.
, QUESTION 7
A client with a T6 spinal cord injury develops a severe throbbing headache, nasal
congestion, and paroxysmal hypertension with a blood pressure of 200 over 110
mmHg. What is the immediate priority nursing action?
A. Administer intravenous antihypertensive medication immediately
B. Sit the client upright and check for bladder distension or a kinked catheter
C. Perform a rectal examination for impaction without checking the bladder
D. Place the client in a flat supine position
ANSWER: B
RATIONALE: This client is experiencing autonomic dysreflexia, a medical
emergency triggered by a noxious stimulus below the injury level, most commonly
bladder distension. The immediate nursing actions are to sit the client upright to
lower blood pressure and identify and remove the triggering stimulus.
QUESTION 8
Which clinical sign differentiates neurogenic shock from hypovolemic shock in a
client with acute spinal cord injury?
A. Tachycardia and cool, clammy skin
B. Bradycardia and warm, dry, flushed skin
C. Tachypnea and elevated blood pressure
D. Anxiety and restlessness
ANSWER: B
RATIONALE: Neurogenic shock involves loss of sympathetic nervous system
vasoconstrictor tone, resulting in unopposed parasympathetic activity
characterized by bradycardia, hypotension, and warm, dry skin, unlike
hypovolemic shock which causes tachycardia and cool skin.
QUESTION 9
