NUR 265
NUR 265 Exam 3 Questions and
Answers 2026
1
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to
notify to PCP
takes warfarin daily--there could be a hemorrhage as part of the injury. warfarin is a
blood thinner
2
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for
ICP--what action requires intervention?
raising the foot of the pt beds-- maintain the head midline/neutral position to prevent
increased ICP
3
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ?
clustering pt care/activities-- cluster care= increased ICP
4
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse
identity as the greatest risk?
20 year old college student who is on the football team.
5
Nurse w assigned pts. which assessment finding would need to be reported to PCP?
1|Page
, NUR 265
the development of asymmetric pupils with no reaction to light in the pt who has a
TBI-- pupillary changes;
6
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has
rhinorrhea and it is positive for glucose--what action is next?
perform a halo sign test--CSG leaking, lab test will be analyzed for glucose and
electrolyte content. place fluid on a while absorbent paper/linen
7
nurse providing dc teaching to pts partner who sustained a mild head injury from
MVC. --what statement requires additional teaching?
I will bring my partner to the ED if they immediately start vomiting--symptoms usually
resolve within 72 hrs NV is expected.
8
Nurse is caring for the following pt. which pt would the nurse see first?
the pt who has a brain injury and a BP change from 110/58 to 134/40-- cushings triad.
severe htn, widening pulse pressure, bradycardia
9
24 hr post op craniotomy. pt is reporting headach 8/10-- what is the next step for the
nurse to take?
perform a neuro assessment--minimize ICP, assess the problem.
sx of increased ICP= headache, deteriorating LOC, restlessness and irritability.
10
2|Page
NUR 265 Exam 3 Questions and
Answers 2026
1
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to
notify to PCP
takes warfarin daily--there could be a hemorrhage as part of the injury. warfarin is a
blood thinner
2
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for
ICP--what action requires intervention?
raising the foot of the pt beds-- maintain the head midline/neutral position to prevent
increased ICP
3
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ?
clustering pt care/activities-- cluster care= increased ICP
4
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse
identity as the greatest risk?
20 year old college student who is on the football team.
5
Nurse w assigned pts. which assessment finding would need to be reported to PCP?
1|Page
, NUR 265
the development of asymmetric pupils with no reaction to light in the pt who has a
TBI-- pupillary changes;
6
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has
rhinorrhea and it is positive for glucose--what action is next?
perform a halo sign test--CSG leaking, lab test will be analyzed for glucose and
electrolyte content. place fluid on a while absorbent paper/linen
7
nurse providing dc teaching to pts partner who sustained a mild head injury from
MVC. --what statement requires additional teaching?
I will bring my partner to the ED if they immediately start vomiting--symptoms usually
resolve within 72 hrs NV is expected.
8
Nurse is caring for the following pt. which pt would the nurse see first?
the pt who has a brain injury and a BP change from 110/58 to 134/40-- cushings triad.
severe htn, widening pulse pressure, bradycardia
9
24 hr post op craniotomy. pt is reporting headach 8/10-- what is the next step for the
nurse to take?
perform a neuro assessment--minimize ICP, assess the problem.
sx of increased ICP= headache, deteriorating LOC, restlessness and irritability.
10
2|Page
