GNRS 558 FINAL EXAM QUESTIONS
AND ANSWERS. VERIFIED 2025/2026.
The nurse provides care for an adolescent client after a skateboard accident that resulted in a
brief episode of unconsicousness. The client's scalp and facial lacerations were treated and
dressed in the emergency department. which nursing care measure is the HIGHEST priority?
1. change the head wound dressings.
2. perform neurological checks frequently.
3. administer antiemetic medications.
4. Manage the client's report of a headache. - ANS 2. perform neurological checks frequently.
The nurse provides care for a school-age client with a TBI. Which symptoms best indicate IICP?
1. Headache, cring, sensitivity to loud noises and bright lights.
2. Widening pulse pressure, slowed respirations, bradycardia.
3. Hypotension, cyanosis, tachcardia.
4. Increased temperature, increase in respirations. - ANS 2. Widening pulse pressure, slowed
respirations, bradycardia.
The nurse provides care for a client diagnosed with a closed head injury and IICP. Whichaction
by the nurse is best?
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,1. Position the clinet with head of bed flat and cleint's head in a neutral positon.
2. Instruct client to exhale when turning or moving in bed.
3. Encourage client to cough and deep breathe every two hours.
4. Suciton client frequently and hyperoxygenate prior to suctioning. - ANS 2. Instruct client to
exhale when turning or moving in bed.
The nurse provides care for a client with expressive aphasia due to dysarthria from a stroke.
Which techniqu is most appropriate for the nurse to use when helping the client communicate?
1. Speaking slowly and with a raised volume
2.Encouraging the client to use gestures
3. Allowing the client to speak in short phrases.
4. reminding the client to swallow before speaking - ANS 3. Allowing the client to speak in
short phrases.
The nurse provides care for a client admitted to the emergency department following an
autoobile accident. The client reports dizziness, and th health care provider suspects a head
injury. The nurse intervenes if which activity is observed?
1. The client is placed in trendelenburg position.
2. the clien'ts neck is immobilized prior to being X-rayed
3. The nursing staff frequently monitors the client's level of consciousness.
4. The nursing staff observes for seizures. - ANS 1. The client is placed in trendelenburg
position.
An unconscious client arrives in the emergency department following a fall that resulted in a
severe head injury. Which action does the nurse take first?
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,1. Assess the patency of the airway.
2. Check the client's pupils for size and reaction to light.
3. Establish the clien'ts LOC
4. evaluate the client's motor response - ANS 1. Assess the patency of the airway.
The nurse notes a client is able to open the eyes spontaneously, follow command to hold up
two fingers, and correclty identify the day of the week and current location. Using the GCS,
which score does the nurse correctly assign to the client?
1. 3
2. 6
3. 10
4. 15 - ANS 4. 15
The nurse assesses for signs associated with IICP in a client diagnosed with a subdural
hematoma. Which is the earliest sign of an increase in ICP?
1. a change in LOC
2. a widening pulse pressure
3. bradycardia
4. decorticate position - ANS 1. a change in LOC
The nurse assess a client diagnosed with cerebral contusion and IICP. Which is the correct initial
nursing aciton?
1. Placing a footboard to decrease foot drop.
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, 2. Encouraging head movement to the right.
3. Elevating HOB 15-30 degrees
4. Suctioning q2h to maintain the airway - ANS 3. Elevating HOB 15-30 degrees
The nurse provides care for a child diagnosed with a serious closed head injury. The client's
parent says to the nurse, "Will my child be all right? Is my child going to die? I'm so scared"
Which response by the nurse is the best?
1. "of course your child will be all right. It will take time for your child to get better."
2. "I'll be avaiable if you have any questions. Here is a booklet on head injuries"
3. It must be frightening to see your child hurt.
4. "Its too soon to know the outcome. Would you like to talk with the HCP? - ANS 3. It must
be frightening to see your child hurt.
Which assessment does the nurse make first when providing care for a client dx with a closed
head injury?
1. Level of cognitive funciton
2. Fluid and Electrolyte balance
3. LOC
4. Airway and Respiratory Status - ANS 4. Airway and Respiratory Status
The nurse provides care for a newly admitted client dx with a head injury. The nurse notes the
client has clear drainage. Which action does the nurse take first?
1. Obtains a specimen of the fluid for culture & sensitivity
2. Checks the nasal draiange for gluocse
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
AND ANSWERS. VERIFIED 2025/2026.
The nurse provides care for an adolescent client after a skateboard accident that resulted in a
brief episode of unconsicousness. The client's scalp and facial lacerations were treated and
dressed in the emergency department. which nursing care measure is the HIGHEST priority?
1. change the head wound dressings.
2. perform neurological checks frequently.
3. administer antiemetic medications.
4. Manage the client's report of a headache. - ANS 2. perform neurological checks frequently.
The nurse provides care for a school-age client with a TBI. Which symptoms best indicate IICP?
1. Headache, cring, sensitivity to loud noises and bright lights.
2. Widening pulse pressure, slowed respirations, bradycardia.
3. Hypotension, cyanosis, tachcardia.
4. Increased temperature, increase in respirations. - ANS 2. Widening pulse pressure, slowed
respirations, bradycardia.
The nurse provides care for a client diagnosed with a closed head injury and IICP. Whichaction
by the nurse is best?
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,1. Position the clinet with head of bed flat and cleint's head in a neutral positon.
2. Instruct client to exhale when turning or moving in bed.
3. Encourage client to cough and deep breathe every two hours.
4. Suciton client frequently and hyperoxygenate prior to suctioning. - ANS 2. Instruct client to
exhale when turning or moving in bed.
The nurse provides care for a client with expressive aphasia due to dysarthria from a stroke.
Which techniqu is most appropriate for the nurse to use when helping the client communicate?
1. Speaking slowly and with a raised volume
2.Encouraging the client to use gestures
3. Allowing the client to speak in short phrases.
4. reminding the client to swallow before speaking - ANS 3. Allowing the client to speak in
short phrases.
The nurse provides care for a client admitted to the emergency department following an
autoobile accident. The client reports dizziness, and th health care provider suspects a head
injury. The nurse intervenes if which activity is observed?
1. The client is placed in trendelenburg position.
2. the clien'ts neck is immobilized prior to being X-rayed
3. The nursing staff frequently monitors the client's level of consciousness.
4. The nursing staff observes for seizures. - ANS 1. The client is placed in trendelenburg
position.
An unconscious client arrives in the emergency department following a fall that resulted in a
severe head injury. Which action does the nurse take first?
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,1. Assess the patency of the airway.
2. Check the client's pupils for size and reaction to light.
3. Establish the clien'ts LOC
4. evaluate the client's motor response - ANS 1. Assess the patency of the airway.
The nurse notes a client is able to open the eyes spontaneously, follow command to hold up
two fingers, and correclty identify the day of the week and current location. Using the GCS,
which score does the nurse correctly assign to the client?
1. 3
2. 6
3. 10
4. 15 - ANS 4. 15
The nurse assesses for signs associated with IICP in a client diagnosed with a subdural
hematoma. Which is the earliest sign of an increase in ICP?
1. a change in LOC
2. a widening pulse pressure
3. bradycardia
4. decorticate position - ANS 1. a change in LOC
The nurse assess a client diagnosed with cerebral contusion and IICP. Which is the correct initial
nursing aciton?
1. Placing a footboard to decrease foot drop.
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, 2. Encouraging head movement to the right.
3. Elevating HOB 15-30 degrees
4. Suctioning q2h to maintain the airway - ANS 3. Elevating HOB 15-30 degrees
The nurse provides care for a child diagnosed with a serious closed head injury. The client's
parent says to the nurse, "Will my child be all right? Is my child going to die? I'm so scared"
Which response by the nurse is the best?
1. "of course your child will be all right. It will take time for your child to get better."
2. "I'll be avaiable if you have any questions. Here is a booklet on head injuries"
3. It must be frightening to see your child hurt.
4. "Its too soon to know the outcome. Would you like to talk with the HCP? - ANS 3. It must
be frightening to see your child hurt.
Which assessment does the nurse make first when providing care for a client dx with a closed
head injury?
1. Level of cognitive funciton
2. Fluid and Electrolyte balance
3. LOC
4. Airway and Respiratory Status - ANS 4. Airway and Respiratory Status
The nurse provides care for a newly admitted client dx with a head injury. The nurse notes the
client has clear drainage. Which action does the nurse take first?
1. Obtains a specimen of the fluid for culture & sensitivity
2. Checks the nasal draiange for gluocse
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
