NUR 265 Exam 3 Med-Surg: Neuro, Shock, and
Mobility Guide Questions And Well Graded
Solutions With Rationales Updated 2026-2027
Ace your NUR 265 Exam 3 with this high-yield nursing study bundle. Features
comprehensive NCLEX-style questions and rationales. Covers critical care
concepts: increased ICP, Cushing’s triad, spinal cord injuries, autonomic
dysreflexia, and Glasgow Coma Scale. Master the 4 stages of shock
(hypovolemic, septic, neurogenic, anaphylactic) and neuro disorders like
Myasthenia Gravis and Guillain-Barré. Perfect for Galen, Arizona, and West
Coast nursing students looking to pass on the first try!
1. A patient with a T4 spinal cord injury reports a sudden, throbbing headache. The
nurse notes facial flushing, a blood pressure of 188/96 mmHg, and a heart rate of 52
beats/min. Which action should the nurse take first?
A) Place the patient in a flat, supine position
B) Check the patient's urinary drainage bag for kinks
C) Administer a PRN dose of intravenous hydralazine
D) Check the patient's fingerstick blood glucose level
B) Check the patient's urinary drainage bag for kinks
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a life-
threatening emergency in spinal cord injuries at or above T6. The first action is to
elevate the head of the bed to 45 degrees or upright (to lower blood pressure) and
remove the noxious stimulus. A distended bladder due to a kinked catheter is the
most common cause. Removing the stimulus resolves the sympathetic surge.
2. A patient with an intracranial pressure (ICP) monitor is admitted following a
traumatic brain injury. The nurse notes an ICP of 24 mmHg and a mean arterial
pressure (MAP) of 84 mmHg. What is this patient's calculated Cerebral Perfusion
Pressure (CPP)?
A) 40 mmHg
B) 60 mmHg
C) 84 mmHg
D) 108 mmHg
B) 60 mmHg
Rationale: Cerebral Perfusion Pressure (CPP) is calculated using the formula:
,. Plugging in the values gives:
. While 60 mmHg is at the lower limit of acceptable levels (normal is 60–100 mmHg),
an ICP of 24 mmHg is elevated and requires prompt intervention to prevent
secondary brain injury.
3. A patient is admitted to the intensive care unit with a severe traumatic brain
injury. Which clinical finding should the nurse identify as a late sign of increased
intracranial pressure (ICP)?
A) Restlessness and mild irritability
B) Slurred speech with a dull headache
C) Heart rate of 48 beats/min with a widened pulse pressure
D) Constricted pupils that react briskly to light
C) Heart rate of 48 beats/min with a widened pulse pressure
Rationale: Bradycardia, severe systolic hypertension with a widened pulse pressure,
and irregular respirations comprise Cushing's triad. This is a late sign of increased
ICP indicating imminent brain herniation and brainstem compression. Alterations in
level of consciousness (restlessness) are early signs.
4. The nurse is planning care for a patient with increased intracranial pressure
(ICP) following a hemorrhagic stroke. Which intervention should the nurse include to
prevent elevations in ICP?
A) Keep the head of the bed elevated at 30 degrees with the neck midline
B) Cluster all nursing care activities back-to-back to promote rest
C) Perform routine endotracheal suctioning every 2 hours
D) Encourage frequent coughing and deep breathing exercises
A) Keep the head of the bed elevated at 30 degrees with the neck midline
,Rationale: Elevating the head of the bed to 30 degrees with a neutral midline neck
position promotes venous drainage from the brain, reducing ICP. Clustering care,
routine suctioning, and coughing all significantly increase intrathoracic pressure and
spike ICP, and are therefore contraindicated.
5. A patient who takes warfarin daily is admitted to the emergency department
after hitting their head in a fall. The patient is awake, alert, and oriented. Which
action is the nurse's highest priority?
A) Administer a mild sedative to keep the patient calm
B) Perform a complete neurovascular assessment of the lower extremities
C) Notify the healthcare provider immediately regarding the anticoagulant history
D) Keep the patient in a flat, supine position for comfort
C) Notify the healthcare provider immediately regarding the anticoagulant
history
Rationale: Patients taking anticoagulants like warfarin who sustain a head injury are
at extremely high risk for rapid, life-threatening intracranial hemorrhage, even if they
initially present with a normal neurological exam. The provider must be notified
immediately to arrange a stat CT scan of the head.
6. The nurse is assessing a patient admitted with a suspected basilar skull
fracture. Which assessment finding confirms the presence of cerebrospinal fluid
(CSF) rhinorrhea?
A) Clear fluid from the nose that tests negative for glucose
B) A yellow ring surrounding a central spot of blood on a gauze pad
C) Thick, purulent drainage from the ear canal
D) Epistaxis that stops completely with direct pressure
B) A yellow ring surrounding a central spot of blood on a gauze pad
Rationale: The "halo sign" (a yellow concentric ring surrounding blood on a gauze) is
a specific indicator of CSF leakage. While CSF contains glucose, testing bloody fluid
for glucose can result in a false positive because blood itself contains glucose;
hence, the halo sign is a more reliable bedside test.
7. A patient with an open chest wound is admitted to the emergency department.
The patient has weak, thready peripheral pulses, a blood pressure of 78/42 mmHg, a
heart rate of 124 beats/min, and severe jugular venous distention. The nurse
suspects obstructive shock caused by cardiac tamponade. Which intervention is the
priority?
A) Prepare for emergency pericardiocentesis
B) Administer a 2 L bolus of 0.45% normal saline
, C) Initiate a continuous infusion of low-dose dopamine
D) Apply a tight, occlusive dressing to the chest wound
A) Prepare for emergency pericardiocentesis
Rationale: Cardiac tamponade is a mechanical emergency where fluid accumulates
in the pericardial sac, compressing the heart and preventing filling. Emergency
pericardiocentesis is required to withdraw fluid and restore cardiac output. Hypotonic
fluids (0.45% NS) are contraindicated in shock resuscitation.
8. A patient is brought to the emergency department in severe septic shock. The
patient is hypotensive, tachycardic, and febrile. Which action should the nurse
complete first?
A) Administer the first dose of a broad-spectrum IV antibiotic
B) Obtain two sets of blood cultures from separate sites
C) Infuse a 30 mL/kg bolus of Lactated Ringer's solution
D) Administer a continuous infusion of norepinephrine
B) Obtain two sets of blood cultures from separate sites
Rationale: Surviving Sepsis guidelines dictate that blood cultures must be drawn
prior to administering broad-spectrum antibiotics to avoid masking the causative
organism, provided it does not delay antibiotic administration for more than 45
minutes. Fluid resuscitation is performed concurrently.
9. The nurse is monitoring a patient in the progressive stage of hypovolemic
shock. Which laboratory value best reflects tissue hypoperfusion and the onset of
anaerobic metabolism?
A) Serum potassium of 3.6 mEq/L
B) Arterial blood gas pH of 7.42
C) Blood urea nitrogen (BUN) of 18 mg/dL
D) Serum lactate level of 4.2 mmol/L
D) Serum lactate level of 4.2 mmol/L
Rationale: A serum lactate level greater than 2.0 mmol/L indicates significant tissue
hypoperfusion and anaerobic metabolism. As oxygen delivery to cells falls, cells
switch from aerobic to anaerobic pathways, producing lactic acid as a byproduct.
This serves as a vital marker for shock severity.
10. A patient experiences a severe allergic reaction to an intravenous antibiotic,
resulting in anaphylactic shock. After stopping the infusion and securing the airway,
which medication should the nurse prepare to administer immediately?
A) Intravenous diphenhydramine
B) Intramuscular epinephrine
Mobility Guide Questions And Well Graded
Solutions With Rationales Updated 2026-2027
Ace your NUR 265 Exam 3 with this high-yield nursing study bundle. Features
comprehensive NCLEX-style questions and rationales. Covers critical care
concepts: increased ICP, Cushing’s triad, spinal cord injuries, autonomic
dysreflexia, and Glasgow Coma Scale. Master the 4 stages of shock
(hypovolemic, septic, neurogenic, anaphylactic) and neuro disorders like
Myasthenia Gravis and Guillain-Barré. Perfect for Galen, Arizona, and West
Coast nursing students looking to pass on the first try!
1. A patient with a T4 spinal cord injury reports a sudden, throbbing headache. The
nurse notes facial flushing, a blood pressure of 188/96 mmHg, and a heart rate of 52
beats/min. Which action should the nurse take first?
A) Place the patient in a flat, supine position
B) Check the patient's urinary drainage bag for kinks
C) Administer a PRN dose of intravenous hydralazine
D) Check the patient's fingerstick blood glucose level
B) Check the patient's urinary drainage bag for kinks
Rationale: The patient is exhibiting classic signs of autonomic dysreflexia, a life-
threatening emergency in spinal cord injuries at or above T6. The first action is to
elevate the head of the bed to 45 degrees or upright (to lower blood pressure) and
remove the noxious stimulus. A distended bladder due to a kinked catheter is the
most common cause. Removing the stimulus resolves the sympathetic surge.
2. A patient with an intracranial pressure (ICP) monitor is admitted following a
traumatic brain injury. The nurse notes an ICP of 24 mmHg and a mean arterial
pressure (MAP) of 84 mmHg. What is this patient's calculated Cerebral Perfusion
Pressure (CPP)?
A) 40 mmHg
B) 60 mmHg
C) 84 mmHg
D) 108 mmHg
B) 60 mmHg
Rationale: Cerebral Perfusion Pressure (CPP) is calculated using the formula:
,. Plugging in the values gives:
. While 60 mmHg is at the lower limit of acceptable levels (normal is 60–100 mmHg),
an ICP of 24 mmHg is elevated and requires prompt intervention to prevent
secondary brain injury.
3. A patient is admitted to the intensive care unit with a severe traumatic brain
injury. Which clinical finding should the nurse identify as a late sign of increased
intracranial pressure (ICP)?
A) Restlessness and mild irritability
B) Slurred speech with a dull headache
C) Heart rate of 48 beats/min with a widened pulse pressure
D) Constricted pupils that react briskly to light
C) Heart rate of 48 beats/min with a widened pulse pressure
Rationale: Bradycardia, severe systolic hypertension with a widened pulse pressure,
and irregular respirations comprise Cushing's triad. This is a late sign of increased
ICP indicating imminent brain herniation and brainstem compression. Alterations in
level of consciousness (restlessness) are early signs.
4. The nurse is planning care for a patient with increased intracranial pressure
(ICP) following a hemorrhagic stroke. Which intervention should the nurse include to
prevent elevations in ICP?
A) Keep the head of the bed elevated at 30 degrees with the neck midline
B) Cluster all nursing care activities back-to-back to promote rest
C) Perform routine endotracheal suctioning every 2 hours
D) Encourage frequent coughing and deep breathing exercises
A) Keep the head of the bed elevated at 30 degrees with the neck midline
,Rationale: Elevating the head of the bed to 30 degrees with a neutral midline neck
position promotes venous drainage from the brain, reducing ICP. Clustering care,
routine suctioning, and coughing all significantly increase intrathoracic pressure and
spike ICP, and are therefore contraindicated.
5. A patient who takes warfarin daily is admitted to the emergency department
after hitting their head in a fall. The patient is awake, alert, and oriented. Which
action is the nurse's highest priority?
A) Administer a mild sedative to keep the patient calm
B) Perform a complete neurovascular assessment of the lower extremities
C) Notify the healthcare provider immediately regarding the anticoagulant history
D) Keep the patient in a flat, supine position for comfort
C) Notify the healthcare provider immediately regarding the anticoagulant
history
Rationale: Patients taking anticoagulants like warfarin who sustain a head injury are
at extremely high risk for rapid, life-threatening intracranial hemorrhage, even if they
initially present with a normal neurological exam. The provider must be notified
immediately to arrange a stat CT scan of the head.
6. The nurse is assessing a patient admitted with a suspected basilar skull
fracture. Which assessment finding confirms the presence of cerebrospinal fluid
(CSF) rhinorrhea?
A) Clear fluid from the nose that tests negative for glucose
B) A yellow ring surrounding a central spot of blood on a gauze pad
C) Thick, purulent drainage from the ear canal
D) Epistaxis that stops completely with direct pressure
B) A yellow ring surrounding a central spot of blood on a gauze pad
Rationale: The "halo sign" (a yellow concentric ring surrounding blood on a gauze) is
a specific indicator of CSF leakage. While CSF contains glucose, testing bloody fluid
for glucose can result in a false positive because blood itself contains glucose;
hence, the halo sign is a more reliable bedside test.
7. A patient with an open chest wound is admitted to the emergency department.
The patient has weak, thready peripheral pulses, a blood pressure of 78/42 mmHg, a
heart rate of 124 beats/min, and severe jugular venous distention. The nurse
suspects obstructive shock caused by cardiac tamponade. Which intervention is the
priority?
A) Prepare for emergency pericardiocentesis
B) Administer a 2 L bolus of 0.45% normal saline
, C) Initiate a continuous infusion of low-dose dopamine
D) Apply a tight, occlusive dressing to the chest wound
A) Prepare for emergency pericardiocentesis
Rationale: Cardiac tamponade is a mechanical emergency where fluid accumulates
in the pericardial sac, compressing the heart and preventing filling. Emergency
pericardiocentesis is required to withdraw fluid and restore cardiac output. Hypotonic
fluids (0.45% NS) are contraindicated in shock resuscitation.
8. A patient is brought to the emergency department in severe septic shock. The
patient is hypotensive, tachycardic, and febrile. Which action should the nurse
complete first?
A) Administer the first dose of a broad-spectrum IV antibiotic
B) Obtain two sets of blood cultures from separate sites
C) Infuse a 30 mL/kg bolus of Lactated Ringer's solution
D) Administer a continuous infusion of norepinephrine
B) Obtain two sets of blood cultures from separate sites
Rationale: Surviving Sepsis guidelines dictate that blood cultures must be drawn
prior to administering broad-spectrum antibiotics to avoid masking the causative
organism, provided it does not delay antibiotic administration for more than 45
minutes. Fluid resuscitation is performed concurrently.
9. The nurse is monitoring a patient in the progressive stage of hypovolemic
shock. Which laboratory value best reflects tissue hypoperfusion and the onset of
anaerobic metabolism?
A) Serum potassium of 3.6 mEq/L
B) Arterial blood gas pH of 7.42
C) Blood urea nitrogen (BUN) of 18 mg/dL
D) Serum lactate level of 4.2 mmol/L
D) Serum lactate level of 4.2 mmol/L
Rationale: A serum lactate level greater than 2.0 mmol/L indicates significant tissue
hypoperfusion and anaerobic metabolism. As oxygen delivery to cells falls, cells
switch from aerobic to anaerobic pathways, producing lactic acid as a byproduct.
This serves as a vital marker for shock severity.
10. A patient experiences a severe allergic reaction to an intravenous antibiotic,
resulting in anaphylactic shock. After stopping the infusion and securing the airway,
which medication should the nurse prepare to administer immediately?
A) Intravenous diphenhydramine
B) Intramuscular epinephrine
