Rasmussen University NUR 2755 Module 1 (pdf) | 2026/2027 | MDC 4
Q&A | Nursing
1. Which of the following best describes the most sensitive indicator of a
change in a client's neurologic status?
A) Pupillary response
B) Level of consciousness
C) Motor strength
D) Vital signs
Correct Answer: Level of consciousness
Rationale: Level of consciousness (LOC) is the most sensitive indicator of
neurologic change. Changes in LOC, such as restlessness, confusion, or
lethargy, are often the earliest signs of deterioration. Pupillary changes and
motor findings are important but typically occur later or indicate more
specific deficits.
2. A client with a head injury has a blood pressure of 180/90 mm Hg, a heart
rate of 50 beats per minute, and irregular respirations. The nurse should
recognize this as:
A) Early signs of increased intracranial pressure
B) Cushing's triad, a late sign of increased intracranial pressure
C) Normal compensatory mechanisms
D) Signs of a stroke
Correct Answer: Cushing's triad, a late sign of increased intracranial pressure
Rationale: Cushing's triad—increasing systolic blood pressure with widened
pulse pressure, bradycardia, and irregular respirations—is a late sign of
,increased intracranial pressure (ICP) indicating impending brain herniation.
This is a medical emergency requiring immediate intervention.
3. A nurse is assessing a client who is 24 hours post-craniotomy. Which
finding is the earliest sign of increased intracranial pressure?
A) Pupillary dilation
B) Decerebrate posturing
C) Restlessness and confusion
D) Bradycardia
Correct Answer: Restlessness and confusion
Rationale: Changes in level of consciousness, such as restlessness and
confusion, are the earliest signs of increased ICP. Pupillary changes,
abnormal posturing, and bradycardia are late signs. Early recognition and
intervention are critical to prevent secondary injury.
4. The nurse is caring for a client with increased intracranial pressure. Which
intervention should the nurse implement to help reduce ICP?
A) Keep the head of the bed flat
B) Elevate the head of the bed to 30 degrees
C) Position the client in a prone position
D) Turn the client's head to the side
Correct Answer: Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous
drainage from the head and helps reduce ICP. Keeping the head flat or
turning the head to the side can increase ICP by impairing venous outflow.
The head and neck should be kept in a midline position.
,5. The nurse is assessing a client's pupil response. A new finding of unequal
pupils is most concerning for which condition?
A) Normal variation
B) Increased intracranial pressure
C) Medication side effect
D) Fatigue
Correct Answer: Increased intracranial pressure
Rationale: New unequal pupils (anisocoria) is a concerning sign that may
indicate increased intracranial pressure or a neurologic injury. While some
individuals may have physiologic anisocoria, a new change requires
immediate further assessment and provider notification.
6. A client with a brain tumor is at risk for which complication related to the
endocrine system?
A) Hyperthyroidism
B) Diabetes insipidus
C) Hyperglycemia
D) Adrenal insufficiency
Correct Answer: Diabetes insipidus
Rationale: Brain injury, including tumors affecting the pituitary or
hypothalamus, can disrupt antidiuretic hormone (ADH) production, leading to
diabetes insipidus (DI). DI is characterized by low ADH, large dilute urine
output, dehydration, and hypernatremia. SIADH (syndrome of inappropriate
antidiuretic hormone) is the opposite condition.
, 7. A client with a brain injury is experiencing large volumes of dilute urine,
thirst, and tachycardia. The nurse should suspect which condition?
A) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
B) Diabetes insipidus (DI)
C) Hyperglycemia
D) Cerebral salt wasting
Correct Answer: Diabetes insipidus (DI)
Rationale: Diabetes insipidus (DI) results from low ADH, causing the kidneys
to excrete large amounts of dilute urine. Symptoms include polyuria,
polydipsia (thirst), dehydration, tachycardia, and hypernatremia. SIADH
causes water retention and hyponatremia.
8. A client with a brain injury is diagnosed with Syndrome of Inappropriate
Antidiuretic Hormone (SIADH). Which laboratory finding would the nurse
expect?
A) Hypernatremia
B) Hyponatremia
C) Hyperkalemia
D) Hypocalcemia
Correct Answer: Hyponatremia
Rationale: SIADH causes water retention due to excess ADH, leading to
dilutional hyponatremia (low serum sodium). Serum osmolality is decreased,
and urine is concentrated. Signs include headache, confusion, and seizures.
9. The nurse is caring for a client with a traumatic brain injury. Which nursing
action is a priority to prevent secondary injury?
Q&A | Nursing
1. Which of the following best describes the most sensitive indicator of a
change in a client's neurologic status?
A) Pupillary response
B) Level of consciousness
C) Motor strength
D) Vital signs
Correct Answer: Level of consciousness
Rationale: Level of consciousness (LOC) is the most sensitive indicator of
neurologic change. Changes in LOC, such as restlessness, confusion, or
lethargy, are often the earliest signs of deterioration. Pupillary changes and
motor findings are important but typically occur later or indicate more
specific deficits.
2. A client with a head injury has a blood pressure of 180/90 mm Hg, a heart
rate of 50 beats per minute, and irregular respirations. The nurse should
recognize this as:
A) Early signs of increased intracranial pressure
B) Cushing's triad, a late sign of increased intracranial pressure
C) Normal compensatory mechanisms
D) Signs of a stroke
Correct Answer: Cushing's triad, a late sign of increased intracranial pressure
Rationale: Cushing's triad—increasing systolic blood pressure with widened
pulse pressure, bradycardia, and irregular respirations—is a late sign of
,increased intracranial pressure (ICP) indicating impending brain herniation.
This is a medical emergency requiring immediate intervention.
3. A nurse is assessing a client who is 24 hours post-craniotomy. Which
finding is the earliest sign of increased intracranial pressure?
A) Pupillary dilation
B) Decerebrate posturing
C) Restlessness and confusion
D) Bradycardia
Correct Answer: Restlessness and confusion
Rationale: Changes in level of consciousness, such as restlessness and
confusion, are the earliest signs of increased ICP. Pupillary changes,
abnormal posturing, and bradycardia are late signs. Early recognition and
intervention are critical to prevent secondary injury.
4. The nurse is caring for a client with increased intracranial pressure. Which
intervention should the nurse implement to help reduce ICP?
A) Keep the head of the bed flat
B) Elevate the head of the bed to 30 degrees
C) Position the client in a prone position
D) Turn the client's head to the side
Correct Answer: Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous
drainage from the head and helps reduce ICP. Keeping the head flat or
turning the head to the side can increase ICP by impairing venous outflow.
The head and neck should be kept in a midline position.
,5. The nurse is assessing a client's pupil response. A new finding of unequal
pupils is most concerning for which condition?
A) Normal variation
B) Increased intracranial pressure
C) Medication side effect
D) Fatigue
Correct Answer: Increased intracranial pressure
Rationale: New unequal pupils (anisocoria) is a concerning sign that may
indicate increased intracranial pressure or a neurologic injury. While some
individuals may have physiologic anisocoria, a new change requires
immediate further assessment and provider notification.
6. A client with a brain tumor is at risk for which complication related to the
endocrine system?
A) Hyperthyroidism
B) Diabetes insipidus
C) Hyperglycemia
D) Adrenal insufficiency
Correct Answer: Diabetes insipidus
Rationale: Brain injury, including tumors affecting the pituitary or
hypothalamus, can disrupt antidiuretic hormone (ADH) production, leading to
diabetes insipidus (DI). DI is characterized by low ADH, large dilute urine
output, dehydration, and hypernatremia. SIADH (syndrome of inappropriate
antidiuretic hormone) is the opposite condition.
, 7. A client with a brain injury is experiencing large volumes of dilute urine,
thirst, and tachycardia. The nurse should suspect which condition?
A) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
B) Diabetes insipidus (DI)
C) Hyperglycemia
D) Cerebral salt wasting
Correct Answer: Diabetes insipidus (DI)
Rationale: Diabetes insipidus (DI) results from low ADH, causing the kidneys
to excrete large amounts of dilute urine. Symptoms include polyuria,
polydipsia (thirst), dehydration, tachycardia, and hypernatremia. SIADH
causes water retention and hyponatremia.
8. A client with a brain injury is diagnosed with Syndrome of Inappropriate
Antidiuretic Hormone (SIADH). Which laboratory finding would the nurse
expect?
A) Hypernatremia
B) Hyponatremia
C) Hyperkalemia
D) Hypocalcemia
Correct Answer: Hyponatremia
Rationale: SIADH causes water retention due to excess ADH, leading to
dilutional hyponatremia (low serum sodium). Serum osmolality is decreased,
and urine is concentrated. Signs include headache, confusion, and seizures.
9. The nurse is caring for a client with a traumatic brain injury. Which nursing
action is a priority to prevent secondary injury?
