NUR 265 Exam 3 | Questions and Answers | 2025 Update | 100%
Correct – Galen College.
Coverage
This original practice bank covers publicly visible NUR 265 Exam 3 areas including traumatic brain injury/increased
ICP, spinal cord injury, myasthenia gravis, Guillain-Barré syndrome, Bell's palsy, trigeminal neuralgia, ALS,
encephalitis/meningitis, burns, and shock. Public listings for current NUR 265 Exam 3 study materials show these
same major areas. cite turn0search0 turn0search5 turn0search9
TBI / Increased ICP
1. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Document the finding but continue the planned care without additional assessment.
B) Reassure the client and wait for the next routine assessment.
C) Address a less urgent problem before this finding.
D) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
Correct Answer: D) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
2. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
B) Document the finding but continue the planned care without additional assessment.
C) Address a less urgent problem before this finding.
D) Reassure the client and wait for the next routine assessment.
Correct Answer: A) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
3. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Document the finding but continue the planned care without additional assessment.
B) Address a less urgent problem before this finding.
, C) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
D) Reassure the client and wait for the next routine assessment.
Correct Answer: C) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
4. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Reassure the client and wait for the next routine assessment.
B) Document the finding but continue the planned care without additional assessment.
C) Address a less urgent problem before this finding.
D) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
Correct Answer: D) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
5. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Reassure the client and wait for the next routine assessment.
B) Address a less urgent problem before this finding.
C) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
D) Document the finding but continue the planned care without additional assessment.
Correct Answer: C) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
6. Which intervention is appropriate for a client at risk for increased intracranial pressure?
A) Address a less urgent problem before this finding.
B) Document the finding but continue the planned care without additional assessment.
C) Reassure the client and wait for the next routine assessment.
D) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Correct Answer: D) Maintain head and neck alignment and elevate the head of the bed as prescribed.
,Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
7. During a nursing shift, which intervention is appropriate for a client at risk for increased intracranial
pressure?
A) Reassure the client and wait for the next routine assessment.
B) Document the finding but continue the planned care without additional assessment.
C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
D) Address a less urgent problem before this finding.
Correct Answer: C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
8. For an NCLEX-style priority question, which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Document the finding but continue the planned care without additional assessment.
B) Reassure the client and wait for the next routine assessment.
C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
D) Address a less urgent problem before this finding.
Correct Answer: C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
9. Which nursing action best addresses the situation? Which intervention is appropriate for a client at risk
for increased intracranial pressure?
A) Maintain head and neck alignment and elevate the head of the bed as prescribed.
B) Address a less urgent problem before this finding.
C) Reassure the client and wait for the next routine assessment.
D) Document the finding but continue the planned care without additional assessment.
Correct Answer: A) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
10. The nurse is planning care. Which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Address a less urgent problem before this finding.
B) Reassure the client and wait for the next routine assessment.
C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
, D) Document the finding but continue the planned care without additional assessment.
Correct Answer: C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
11. Which finding is most concerning for worsening intracranial pressure?
A) Address a less urgent problem before this finding.
B) Reassure the client and wait for the next routine assessment.
C) Document the finding but continue the planned care without additional assessment.
D) A decreasing level of consciousness.
Correct Answer: D) A decreasing level of consciousness.
Rationale: A declining level of consciousness is an important sign of neurologic deterioration.
12. During a nursing shift, which finding is most concerning for worsening intracranial pressure?
A) Reassure the client and wait for the next routine assessment.
B) A decreasing level of consciousness.
C) Document the finding but continue the planned care without additional assessment.
D) Address a less urgent problem before this finding.
Correct Answer: B) A decreasing level of consciousness.
Rationale: A declining level of consciousness is an important sign of neurologic deterioration.
13. For an NCLEX-style priority question, which finding is most concerning for worsening intracranial
pressure?
A) Address a less urgent problem before this finding.
B) Document the finding but continue the planned care without additional assessment.
C) Reassure the client and wait for the next routine assessment.
D) A decreasing level of consciousness.
Correct Answer: D) A decreasing level of consciousness.
Rationale: A declining level of consciousness is an important sign of neurologic deterioration.
14. Which nursing action best addresses the situation? Which finding is most concerning for worsening
intracranial pressure?
A) Reassure the client and wait for the next routine assessment.
B) Address a less urgent problem before this finding.
C) Document the finding but continue the planned care without additional assessment.
Correct – Galen College.
Coverage
This original practice bank covers publicly visible NUR 265 Exam 3 areas including traumatic brain injury/increased
ICP, spinal cord injury, myasthenia gravis, Guillain-Barré syndrome, Bell's palsy, trigeminal neuralgia, ALS,
encephalitis/meningitis, burns, and shock. Public listings for current NUR 265 Exam 3 study materials show these
same major areas. cite turn0search0 turn0search5 turn0search9
TBI / Increased ICP
1. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Document the finding but continue the planned care without additional assessment.
B) Reassure the client and wait for the next routine assessment.
C) Address a less urgent problem before this finding.
D) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
Correct Answer: D) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
2. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
B) Document the finding but continue the planned care without additional assessment.
C) Address a less urgent problem before this finding.
D) Reassure the client and wait for the next routine assessment.
Correct Answer: A) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
3. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Document the finding but continue the planned care without additional assessment.
B) Address a less urgent problem before this finding.
, C) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
D) Reassure the client and wait for the next routine assessment.
Correct Answer: C) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
4. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Reassure the client and wait for the next routine assessment.
B) Document the finding but continue the planned care without additional assessment.
C) Address a less urgent problem before this finding.
D) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
Correct Answer: D) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
5. A client with a traumatic brain injury develops a new fixed, dilated pupil. What is the priority response?
A) Reassure the client and wait for the next routine assessment.
B) Address a less urgent problem before this finding.
C) Perform an immediate neurologic assessment and notify the provider/rapid-response team for acute
deterioration.
D) Document the finding but continue the planned care without additional assessment.
Correct Answer: C) Perform an immediate neurologic assessment and notify the provider/rapid-response
team for acute deterioration.
Rationale: A new fixed pupil can indicate severe neurologic deterioration and possible herniation, requiring
immediate escalation.
6. Which intervention is appropriate for a client at risk for increased intracranial pressure?
A) Address a less urgent problem before this finding.
B) Document the finding but continue the planned care without additional assessment.
C) Reassure the client and wait for the next routine assessment.
D) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Correct Answer: D) Maintain head and neck alignment and elevate the head of the bed as prescribed.
,Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
7. During a nursing shift, which intervention is appropriate for a client at risk for increased intracranial
pressure?
A) Reassure the client and wait for the next routine assessment.
B) Document the finding but continue the planned care without additional assessment.
C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
D) Address a less urgent problem before this finding.
Correct Answer: C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
8. For an NCLEX-style priority question, which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Document the finding but continue the planned care without additional assessment.
B) Reassure the client and wait for the next routine assessment.
C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
D) Address a less urgent problem before this finding.
Correct Answer: C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
9. Which nursing action best addresses the situation? Which intervention is appropriate for a client at risk
for increased intracranial pressure?
A) Maintain head and neck alignment and elevate the head of the bed as prescribed.
B) Address a less urgent problem before this finding.
C) Reassure the client and wait for the next routine assessment.
D) Document the finding but continue the planned care without additional assessment.
Correct Answer: A) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
10. The nurse is planning care. Which intervention is appropriate for a client at risk for increased
intracranial pressure?
A) Address a less urgent problem before this finding.
B) Reassure the client and wait for the next routine assessment.
C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
, D) Document the finding but continue the planned care without additional assessment.
Correct Answer: C) Maintain head and neck alignment and elevate the head of the bed as prescribed.
Rationale: Neutral alignment and appropriate head elevation can promote venous drainage and help limit
ICP.
11. Which finding is most concerning for worsening intracranial pressure?
A) Address a less urgent problem before this finding.
B) Reassure the client and wait for the next routine assessment.
C) Document the finding but continue the planned care without additional assessment.
D) A decreasing level of consciousness.
Correct Answer: D) A decreasing level of consciousness.
Rationale: A declining level of consciousness is an important sign of neurologic deterioration.
12. During a nursing shift, which finding is most concerning for worsening intracranial pressure?
A) Reassure the client and wait for the next routine assessment.
B) A decreasing level of consciousness.
C) Document the finding but continue the planned care without additional assessment.
D) Address a less urgent problem before this finding.
Correct Answer: B) A decreasing level of consciousness.
Rationale: A declining level of consciousness is an important sign of neurologic deterioration.
13. For an NCLEX-style priority question, which finding is most concerning for worsening intracranial
pressure?
A) Address a less urgent problem before this finding.
B) Document the finding but continue the planned care without additional assessment.
C) Reassure the client and wait for the next routine assessment.
D) A decreasing level of consciousness.
Correct Answer: D) A decreasing level of consciousness.
Rationale: A declining level of consciousness is an important sign of neurologic deterioration.
14. Which nursing action best addresses the situation? Which finding is most concerning for worsening
intracranial pressure?
A) Reassure the client and wait for the next routine assessment.
B) Address a less urgent problem before this finding.
C) Document the finding but continue the planned care without additional assessment.
