,Arizona College NUR 445 Exam 3 | Acute & Chronic
Health Disruptions Adult III (2026) Q&A
1. A nurse is caring for a patient with a traumatic brain injury who has a ventriculostomy
drain in place. Which finding requires immediate intervention?
A) Drainage of 5 mL of clear cerebrospinal fluid in the past hour
B) Intracranial pressure reading of 22 mm Hg sustained for 5 minutes
C) Patient opens eyes spontaneously and follows simple commands
D) Small amount of serosanguineous drainage at the insertion site
Correct Answer: Intracranial pressure reading of 22 mm Hg sustained for 5 minutes
Rationale: A sustained ICP above 20 mm Hg indicates uncontrolled intracranial
hypertension and requires immediate intervention to prevent herniation. Clear CSF
drainage and a small amount of serosanguineous drainage at the insertion site are expected
findings. The patient following commands indicates intact neurologic function.
2. A patient with a subarachnoid hemorrhage is admitted to the ICU. The nurse should
monitor for which complication?
A) Hyperglycemia
B) Vasospasm leading to delayed cerebral ischemia
C) Hypernatremia
D) Bradycardia
Correct Answer: Vasospasm leading to delayed cerebral ischemia
,Rationale: Vasospasm is a major complication of subarachnoid hemorrhage, typically
occurring 4 to 14 days after the initial bleed. It can lead to delayed cerebral ischemia and
infarction. Monitoring for neurologic deterioration is essential.
3. Which assessment finding is most characteristic of a subdural hematoma?
A) Rapid onset of symptoms within minutes of injury
B) Neurologic deterioration occurring over hours to days
C) Clear cerebrospinal fluid leaking from the nose
D) Lucid interval followed by rapid deterioration
Correct Answer: Neurologic deterioration occurring over hours to days
Rationale: A subdural hematoma typically develops from venous bleeding, with
symptoms appearing gradually over hours to days. An epidural hematoma is characterized
by a lucid interval followed by rapid deterioration. CSF rhinorrhea suggests a basilar skull
fracture.
4. A nurse is assessing a patient with a brain tumor. Which finding is most concerning?
A) Headache relieved by acetaminophen
B) New-onset seizure activity
C) Occasional nausea in the morning
D) Mild memory difficulty
Correct Answer: New-onset seizure activity
, Rationale: New-onset seizures in a patient with a brain tumor indicate cortical irritation
and may signal tumor growth, edema, or increased intracranial pressure. This requires
immediate evaluation and intervention.
5. Which medication is used to reduce cerebral edema in a patient with a brain tumor?
A) Mannitol
B) Heparin
C) Aspirin
D) Acetaminophen
Correct Answer: Mannitol
Rationale: Mannitol is an osmotic diuretic that draws fluid from brain tissue into the
bloodstream, reducing cerebral edema and intracranial pressure. Heparin and aspirin
increase bleeding risk and are contraindicated.
6. A patient with amyotrophic lateral sclerosis (ALS) is being taught about the disease.
Which statement indicates understanding?
A) "This disease primarily affects my sensory nerves."
B) "My muscles will progressively weaken, but my thinking will remain clear."
C) "I will likely experience numbness in my hands and feet."
D) "Vision loss is an expected part of this disease."
Correct Answer: "My muscles will progressively weaken, but my thinking will remain
clear."
Health Disruptions Adult III (2026) Q&A
1. A nurse is caring for a patient with a traumatic brain injury who has a ventriculostomy
drain in place. Which finding requires immediate intervention?
A) Drainage of 5 mL of clear cerebrospinal fluid in the past hour
B) Intracranial pressure reading of 22 mm Hg sustained for 5 minutes
C) Patient opens eyes spontaneously and follows simple commands
D) Small amount of serosanguineous drainage at the insertion site
Correct Answer: Intracranial pressure reading of 22 mm Hg sustained for 5 minutes
Rationale: A sustained ICP above 20 mm Hg indicates uncontrolled intracranial
hypertension and requires immediate intervention to prevent herniation. Clear CSF
drainage and a small amount of serosanguineous drainage at the insertion site are expected
findings. The patient following commands indicates intact neurologic function.
2. A patient with a subarachnoid hemorrhage is admitted to the ICU. The nurse should
monitor for which complication?
A) Hyperglycemia
B) Vasospasm leading to delayed cerebral ischemia
C) Hypernatremia
D) Bradycardia
Correct Answer: Vasospasm leading to delayed cerebral ischemia
,Rationale: Vasospasm is a major complication of subarachnoid hemorrhage, typically
occurring 4 to 14 days after the initial bleed. It can lead to delayed cerebral ischemia and
infarction. Monitoring for neurologic deterioration is essential.
3. Which assessment finding is most characteristic of a subdural hematoma?
A) Rapid onset of symptoms within minutes of injury
B) Neurologic deterioration occurring over hours to days
C) Clear cerebrospinal fluid leaking from the nose
D) Lucid interval followed by rapid deterioration
Correct Answer: Neurologic deterioration occurring over hours to days
Rationale: A subdural hematoma typically develops from venous bleeding, with
symptoms appearing gradually over hours to days. An epidural hematoma is characterized
by a lucid interval followed by rapid deterioration. CSF rhinorrhea suggests a basilar skull
fracture.
4. A nurse is assessing a patient with a brain tumor. Which finding is most concerning?
A) Headache relieved by acetaminophen
B) New-onset seizure activity
C) Occasional nausea in the morning
D) Mild memory difficulty
Correct Answer: New-onset seizure activity
, Rationale: New-onset seizures in a patient with a brain tumor indicate cortical irritation
and may signal tumor growth, edema, or increased intracranial pressure. This requires
immediate evaluation and intervention.
5. Which medication is used to reduce cerebral edema in a patient with a brain tumor?
A) Mannitol
B) Heparin
C) Aspirin
D) Acetaminophen
Correct Answer: Mannitol
Rationale: Mannitol is an osmotic diuretic that draws fluid from brain tissue into the
bloodstream, reducing cerebral edema and intracranial pressure. Heparin and aspirin
increase bleeding risk and are contraindicated.
6. A patient with amyotrophic lateral sclerosis (ALS) is being taught about the disease.
Which statement indicates understanding?
A) "This disease primarily affects my sensory nerves."
B) "My muscles will progressively weaken, but my thinking will remain clear."
C) "I will likely experience numbness in my hands and feet."
D) "Vision loss is an expected part of this disease."
Correct Answer: "My muscles will progressively weaken, but my thinking will remain
clear."
