NUR265 Advanced Concepts of Medical-Surgical Nursing
Exam 3 Actual Exam 2026/2027 | Complete Exam-Style
Questions with Detailed Rationales | Pass Guaranteed –
A+ Graded
## SECTION I: Neurological Disorders – Traumatic Brain Injury (TBI) & Intracranial Pressure (ICP)
---
**Q1:** A nurse is assessing a client who sustained a closed head injury 2 hours ago. Which finding
is the earliest indicator of neurologic deterioration?
A. Pupillary changes
B. Decreased level of consciousness
C. Decorticate posturing
D. Cushing's triad
**Correct Answer: B**
Rationale: Correct because the earliest sign of neurologic deterioration in a client with TBI is a
decreased level of consciousness. This finding precedes pupillary changes, posturing, and Cushing's
triad, which represent later signs of increased ICP. The nurse must monitor LOC closely to detect
deterioration early.
---
**Q2:** A client with a severe TBI presents with bradycardia, hypertension with a widened pulse
pressure, and irregular respirations. The nurse recognizes these findings as indicative of what
condition?
A. Neurogenic shock
B. Cushing's triad
C. Autonomic dysreflexia
D. Brainstem herniation
**Correct Answer: B**
Rationale: Correct because Cushing's triad, consisting of bradycardia, hypertension with widened
pulse pressure, and irregular respirations, is a classic sign of critically increased intracranial
pressure. This represents the brain's compensatory response to maintain cerebral perfusion and
requires immediate intervention.
---
**Q3:** A client is admitted following a motor vehicle accident. The Glasgow Coma Scale (GCS)
score is documented as 7. The nurse interprets this finding as indicating:
A. Mild brain injury
B. Moderate brain injury
,C. Coma
D. Full recovery potential
**Correct Answer: C**
Rationale: Correct because a GCS score of ≤ 7 is interpreted as coma. A GCS of 3-8 indicates severe
brain injury with coma, 9-12 indicates moderate injury, and 13-15 indicates mild injury. The nurse
must implement appropriate interventions for a comatose client, including airway protection and ICP
monitoring.
---
**Q4:** A nurse is caring for a client with increased ICP. Which nursing intervention is most
appropriate to prevent further increases in ICP?
A. Cluster care activities to allow for rest periods
B. Maintain the head and neck in a midline neutral position
C. Encourage deep breathing and coughing every 2 hours
D. Position the client with the head of bed flat
**Correct Answer: B**
Rationale: Correct because maintaining the head and neck in a midline neutral position promotes
venous drainage from the brain and prevents jugular venous compression, which can increase ICP.
The nurse should avoid clustering care activities, discourage forceful coughing, and elevate the head
of bed 30-45 degrees unless contraindicated.
---
**Q5:** A client with a TBI requires suctioning. The nurse should implement which action to
minimize the risk of increased ICP?
A. Suction for no longer than 10 seconds
B. Hyperoxygenate before and after suctioning
C. Use a large-bore suction catheter
D. Suction every 15 minutes routinely
**Correct Answer: B**
Rationale: Correct because hyperoxygenating the client before and after suctioning prevents hypoxia,
which can cause cerebral vasodilation and further increase ICP. The nurse should limit suctioning to
10-15 seconds, use the appropriate catheter size, and suction only as needed rather than on a
routine schedule.
---
**Q6:** A nurse is caring for a client with a basilar skull fracture. The client reports clear fluid
draining from the nose. Which nursing action is the priority?
A. Insert a nasal packing to stop the drainage
B. Perform a halo sign test on the drainage
C. Have the client blow their nose gently
D. Administer a decongestant
, **Correct Answer: B**
Rationale: Correct because clear or bloody nasal drainage that is positive for glucose may indicate a
cerebrospinal fluid (CSF) leak. The nurse should perform a halo sign test by placing drainage on filter
paper; a CSF leak will produce a central blood stain with a clear yellow ring (halo). The nurse must
never insert packing or have the client blow their nose, as this can introduce infection or increase
ICP.
---
**Q7:** A client with a basilar skull fracture becomes increasingly irritable and restless. What is the
nurse's priority action?
A. Administer a sedative as ordered
B. Apply soft wrist restraints for safety
C. Follow up with the primary healthcare provider immediately
D. Dim the lights and minimize stimulation
**Correct Answer: C**
Rationale: Correct because a client with a basilar skull fracture who becomes irritable and restless
may be experiencing increased ICP or neurologic deterioration. This change in mental status is a
priority finding that requires immediate follow-up with the primary healthcare provider for further
assessment and intervention.
---
**Q8:** A client presents to the emergency department following a minor head injury. The client
reports amnesia, dizziness, and sensitivity to light and noise. These findings are consistent with:
A. Epidural hematoma
B. Mild traumatic brain injury
C. Subdural hematoma
D. Diffuse axonal injury
**Correct Answer: B**
Rationale: Correct because amnesia, dizziness, and sensitivity to light and noise are classic findings
consistent with a mild TBI (concussion). The nurse should provide client education on
post-concussion syndrome, monitor for worsening symptoms, and ensure the client has a
responsible adult to observe them for 24 hours.
---
**Q9:** A nurse is conducting a community health presentation on fall prevention. Which population
is at the greatest risk for traumatic brain injury?
A. Adolescents ages 13-18
B. Young adults ages 19-25
C. Older adults
D. School-age children ages 6-12
**Correct Answer: C**
Exam 3 Actual Exam 2026/2027 | Complete Exam-Style
Questions with Detailed Rationales | Pass Guaranteed –
A+ Graded
## SECTION I: Neurological Disorders – Traumatic Brain Injury (TBI) & Intracranial Pressure (ICP)
---
**Q1:** A nurse is assessing a client who sustained a closed head injury 2 hours ago. Which finding
is the earliest indicator of neurologic deterioration?
A. Pupillary changes
B. Decreased level of consciousness
C. Decorticate posturing
D. Cushing's triad
**Correct Answer: B**
Rationale: Correct because the earliest sign of neurologic deterioration in a client with TBI is a
decreased level of consciousness. This finding precedes pupillary changes, posturing, and Cushing's
triad, which represent later signs of increased ICP. The nurse must monitor LOC closely to detect
deterioration early.
---
**Q2:** A client with a severe TBI presents with bradycardia, hypertension with a widened pulse
pressure, and irregular respirations. The nurse recognizes these findings as indicative of what
condition?
A. Neurogenic shock
B. Cushing's triad
C. Autonomic dysreflexia
D. Brainstem herniation
**Correct Answer: B**
Rationale: Correct because Cushing's triad, consisting of bradycardia, hypertension with widened
pulse pressure, and irregular respirations, is a classic sign of critically increased intracranial
pressure. This represents the brain's compensatory response to maintain cerebral perfusion and
requires immediate intervention.
---
**Q3:** A client is admitted following a motor vehicle accident. The Glasgow Coma Scale (GCS)
score is documented as 7. The nurse interprets this finding as indicating:
A. Mild brain injury
B. Moderate brain injury
,C. Coma
D. Full recovery potential
**Correct Answer: C**
Rationale: Correct because a GCS score of ≤ 7 is interpreted as coma. A GCS of 3-8 indicates severe
brain injury with coma, 9-12 indicates moderate injury, and 13-15 indicates mild injury. The nurse
must implement appropriate interventions for a comatose client, including airway protection and ICP
monitoring.
---
**Q4:** A nurse is caring for a client with increased ICP. Which nursing intervention is most
appropriate to prevent further increases in ICP?
A. Cluster care activities to allow for rest periods
B. Maintain the head and neck in a midline neutral position
C. Encourage deep breathing and coughing every 2 hours
D. Position the client with the head of bed flat
**Correct Answer: B**
Rationale: Correct because maintaining the head and neck in a midline neutral position promotes
venous drainage from the brain and prevents jugular venous compression, which can increase ICP.
The nurse should avoid clustering care activities, discourage forceful coughing, and elevate the head
of bed 30-45 degrees unless contraindicated.
---
**Q5:** A client with a TBI requires suctioning. The nurse should implement which action to
minimize the risk of increased ICP?
A. Suction for no longer than 10 seconds
B. Hyperoxygenate before and after suctioning
C. Use a large-bore suction catheter
D. Suction every 15 minutes routinely
**Correct Answer: B**
Rationale: Correct because hyperoxygenating the client before and after suctioning prevents hypoxia,
which can cause cerebral vasodilation and further increase ICP. The nurse should limit suctioning to
10-15 seconds, use the appropriate catheter size, and suction only as needed rather than on a
routine schedule.
---
**Q6:** A nurse is caring for a client with a basilar skull fracture. The client reports clear fluid
draining from the nose. Which nursing action is the priority?
A. Insert a nasal packing to stop the drainage
B. Perform a halo sign test on the drainage
C. Have the client blow their nose gently
D. Administer a decongestant
, **Correct Answer: B**
Rationale: Correct because clear or bloody nasal drainage that is positive for glucose may indicate a
cerebrospinal fluid (CSF) leak. The nurse should perform a halo sign test by placing drainage on filter
paper; a CSF leak will produce a central blood stain with a clear yellow ring (halo). The nurse must
never insert packing or have the client blow their nose, as this can introduce infection or increase
ICP.
---
**Q7:** A client with a basilar skull fracture becomes increasingly irritable and restless. What is the
nurse's priority action?
A. Administer a sedative as ordered
B. Apply soft wrist restraints for safety
C. Follow up with the primary healthcare provider immediately
D. Dim the lights and minimize stimulation
**Correct Answer: C**
Rationale: Correct because a client with a basilar skull fracture who becomes irritable and restless
may be experiencing increased ICP or neurologic deterioration. This change in mental status is a
priority finding that requires immediate follow-up with the primary healthcare provider for further
assessment and intervention.
---
**Q8:** A client presents to the emergency department following a minor head injury. The client
reports amnesia, dizziness, and sensitivity to light and noise. These findings are consistent with:
A. Epidural hematoma
B. Mild traumatic brain injury
C. Subdural hematoma
D. Diffuse axonal injury
**Correct Answer: B**
Rationale: Correct because amnesia, dizziness, and sensitivity to light and noise are classic findings
consistent with a mild TBI (concussion). The nurse should provide client education on
post-concussion syndrome, monitor for worsening symptoms, and ensure the client has a
responsible adult to observe them for 24 hours.
---
**Q9:** A nurse is conducting a community health presentation on fall prevention. Which population
is at the greatest risk for traumatic brain injury?
A. Adolescents ages 13-18
B. Young adults ages 19-25
C. Older adults
D. School-age children ages 6-12
**Correct Answer: C**
