Exam 3: TBI (NCLEX) Graded A 2025

1. Patient with head injury. Which of the following are manifestations of Increased ICP? SELECT ALL THAT APPLY A.Headache. B.Tachycardia C.Hypotension D.Pupillary changes. E.Abnormal posturing. - ADE 2. Abnormal extension (Decerebrate) posturing is characterized by which of the following? A. Extension of extremities and pronation of the arms B. Flexion of extremities and pronation of arms C. Upper extremity flexion with lower extremity extension D. Upper extremity extension with lower extremity flexion. - D 3. A client with increased ICP is prescribed the following tests. The nurse would clarify which test with the physician? A. MRI B. LP C. CT Scan. D. Cerebral angiography - B 4. Client sustained closed head injury. Nurse assesses for which early sign of impending neurological deterioration? A. Loss of corneal reflex B.Increased visual acuity C.Bilateral pupil equality and reactivity D.Ipsilateral pupil dilation. - D 5. Client with diagnosis of SIADH. The nurse would expect to see what laboratory finding? A. Serum sodium 125. B. Serum potassium 2.7 C. Serum glucose 250 D. Serum chloride 110 - A 6. The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? select all that apply. A. systolic blood pressure B. urine output C. breath sounds D. cerebral perfusion pressure - AD 7. Which activity should the nurse encourage the patient to avoid when there is a risk for intracranial pressure(ICP)? A. deep breathing B. turning C. coughing D. passive range-of-motion exercises - C 8. the nurse is caring for the client with increased intracranial pressure. the nurse would note which trend in vital sings if the intracranial pressure is rising? A. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. increasing temperature, decreasing pulse, decreasing respirations. increasing blood pressure C. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure - B 9. a client recovering from a head injury is participating in care. the nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? A. blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning - D 10. a client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurses the cerebrospinal fluid is present? A. fluid is clear and tests negative for glucose B. fluid is grossly bloody in appearance and has a pH of 6 C. fluid clumps together on the dressing and has a pH of 7 D. fluid separates into concentric rings and tests positive for glucose - D 11. the nurse is assessing the motor function of an unconscious client. the nurse should plan to use which techniques to test the clients peripheral response to pain? A. sternal rub B. nail bed pressure C. pressure on the orbital rim D. squeezing of the sternocleidomastoid muscle - B 12. in which of the following positions should the nurse place a client following a craniotomy for evacuation of a subdural hematoma of the frontal lobe? A. supine B. Prone C. semi-fowlers D. sims - C 13. an unconscious client assumes a decerebrate posture in response to any noxious stimuli. when drawing a blood sample, the nurse should expect the client to: A. rigidly extend all four extremities B. internally flex the arms and extend the legs C. tightly curl into a fetal position D. internally rotate the arms and legs - A 14. a nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. which of the following is the priority assessment? A. glasgow coma scale B. cranial nerve function C. oxygen saturation D. pupillary response - C 15. a nurse is caring for a client who has a closed had injury with ICp readings ranging from 16-22 mmH of the following actions should the nurse take to decrease the potential for raising the clients ICP (select all that apply) A. suction the endotracheal tube frequently B. decrease the noise level in the clients room C. elevate the clients head on two pillow D. administer stool softener - D 16. a nures in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. which of the following assessment findings are indicative of increased ICP (select all that apply) A. headache B. dilated pupils C. tachycardia D. decorticate posturing E. hypotension - ABD 17. a nurse is caring for a client who has increased ICP and new prescription for mannitol. for which of the following adverse effects should the nurse monitor? A. hyperglycemia B. hyponatremia C. hypervolemia D. oliguria - B 18. The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to a. obtain a specimen of the fluid and send for culture and sensitivity. b. take the patient's temperature to determine whether a fever is present. c. check the nasal drainage for glucose with a Dextrostik or Testape. d. have the patient to blow the nose and then check the nares for redness. - C 19. A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30 - C 20. When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light. - C 21. A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a. Document and continue to monitor the parameters. b. Elevate the head of the patient's bed. c. Notify the health care provider about the assessments.