NUR 240 FINAL EXAM TESTBANK QUESTIONS 2025 400+ REAL EXAM
QUESTIONS WITH DETAILED ANSWERS PLUS RATIONALES |MOST
TESTED QUESTIONS AND CORRECT ANSWERS |100% ACCURATE|GET
IT RIGHT!!
Question 1
You are caring for a patient who sustained a basilar skull fracture. The nurse observes clear fluid
draining from the patient's nostrils. Which test should be performed on the fluid to confirm if it is
cerebrospinal fluid (CSF)?
A) Test for protein
B) Test for glucose
C) Test for ketones
D) Test for specific gravity
Correct Answer: B) Test for glucose
Rationale: Cerebrospinal fluid contains glucose, whereas normal nasal secretions do not. The
presence of glucose in the clear drainage is a positive sign that it is CSF and indicates a tear
in the dura mater, which requires immediate physician notification.
Question 2
This image shows a patient with rigid extension of the arms and legs, with the arms pronated and
the feet in plantar flexion. This type of posturing is known as:
A) decorticate
B) decerebrate
C) flaccid
D) opisthotonos
Correct Answer: B) decerebrate
Rationale: Decerebrate posturing is characterized by rigid extension and pronation of the
arms, as well as extension of the legs. It typically indicates more severe damage to the
brainstem.
Question 3
This image shows a patient with abnormal flexion of the upper extremities and extension of the lower
extremities. The arms are adducted and flexed against the chest. This type of posturing is known as:
A) decorticate
B) decerebrate
C) flaccid
D) opisthotonos
Correct Answer: A) decorticate
Rationale: Decorticate posturing is characterized by the arms being flexed, or bent inward on
the chest, with the hands clenched into fists, and the legs extended. It indicates damage to
the cerebral hemispheres, thalamus, or midbrain.
,Question 4
A patient is admitted to the ED after a head injury. They initially lost consciousness, then were alert
and talking for about an hour, and then rapidly lost consciousness again. This clinical presentation is
a classic sign of which condition?
A) Subdural hematoma
B) Subarachnoid hemorrhage
C) Epidural hematoma
D) Ischemic stroke
Correct Answer: C) Epidural hematoma
Rationale: An epidural hematoma, typically caused by an arterial bleed, classically presents
with a "lucid interval." The patient may have an initial loss of consciousness, followed by a
period of being alert, before a rapid decline in neurological status as the hematoma expands
and compresses the brain.
Question 5
What is the primary purpose of a halo fixation device for a patient with a cervical spinal cord injury?
A) To provide traction to the cervical spine
B) To provide rigid immobilization of the cervical spine
C) To assist with ambulation
D) To monitor intracranial pressure
Correct Answer: B) To provide rigid immobilization of the cervical spine
Rationale: A halo fixation device is a type of external brace that completely immobilizes the
head and neck. Its purpose is to stabilize the cervical spine after a severe fracture or surgery
to allow for proper healing and prevent further injury.
Question 6
A patient is being discharged with a halo fixation device. The nurse should educate the patient that
the device will typically be worn for approximately how long?
A) 2-4 weeks
B) 4-6 weeks
C) 8-12 weeks
D) 6-9 months
Correct Answer: C) 8-12 weeks
Rationale: The duration of halo fixation is typically around 8 to 12 weeks to allow for adequate
bone healing and fusion of the cervical spine. The exact duration is determined by the
physician based on follow-up imaging.
Question 7
A patient with a traumatic brain injury is exhibiting Cushing's triad. Which of the following sets of vital
signs is consistent with this condition?
,A) BP 90/60, HR 120, RR 28
B) BP 180/90, HR 50, RR 12 and irregular
C) BP 120/80, HR 75, RR 18
D) BP 90/50, HR 45, RR 10
Correct Answer: B) BP 180/90, HR 50, RR 12 and irregular
Rationale: Cushing's triad is a late, ominous sign of significantly increased intracranial
pressure (ICP). It is characterized by systolic hypertension with a widened pulse pressure,
bradycardia (slow heart rate), and an irregular respiratory pattern.
Question 8
In a patient with increased intracranial pressure (ICP), which ventilator setting can further increase
the ICP and should be used with caution?
A) High PEEP (Positive End-Expiratory Pressure)
B) Low respiratory rate
C) Low tidal volume
D) High FiO2 (Fraction of Inspired Oxygen)
Correct Answer: A) High PEEP (Positive End-Expiratory Pressure)
Rationale: High levels of PEEP can increase intrathoracic pressure, which can impede venous
outflow from the brain. This backup of venous blood can lead to an increase in intracranial
pressure and should be monitored closely in patients with head injuries.
Question 9
You are caring for a patient with increased intracranial pressure (ICP). Which nursing action is most
likely to cause a transient increase in their ICP?
A) Administering a stool softener
B) Keeping the room quiet and dark
C) Suctioning the patient's airway
D) Placing the patient's head in neutral alignment
Correct Answer: C) Suctioning the patient's airway
Rationale: Suctioning can trigger a cough reflex, which significantly increases intrathoracic
and intracranial pressure. While sometimes necessary, suctioning should be performed
quickly and efficiently, and the patient should be hyperoxygenated before and after to
minimize complications.
Question 10
Which of the following represents correct positioning for a patient with increased intracranial
pressure (ICP)?
A) Head of bed flat with knees and hips flexed
B) Head of bed at 30 degrees with the head in neutral alignment
, C) Trendelenburg position to increase cerebral perfusion
D) Side-lying with a pillow between the flexed knees
Correct Answer: B) Head of bed at 30 degrees with the head in neutral alignment
Rationale: Elevating the head of the bed to 30 degrees helps promote venous drainage from
the brain, which can lower ICP. Keeping the head and neck in a neutral, midline position
prevents kinking of the jugular veins and further facilitates venous outflow. Flexion of the
hips and neck should be avoided.
Question 11
What is the mechanism of action of mannitol when administered to a patient with increased
intracranial pressure?
A) It is a loop diuretic that reduces total body fluid.
B) It is an osmotic diuretic that moves fluid from the brain tissue into the blood vessels.
C) It is a corticosteroid that reduces inflammation in the brain.
D) It is a sedative that decreases the metabolic demands of the brain.
E) It is a vasopressor that increases cerebral perfusion pressure.
Correct Answer: B) It is an osmotic diuretic that moves fluid from the brain tissue into the
blood vessels.
Rationale: Mannitol is a large sugar molecule that increases the osmolarity of the blood. This
creates an osmotic gradient that pulls excess water (cerebral edema) out of the brain
parenchyma and into the intravascular space, where it can then be excreted by the kidneys,
thus reducing ICP.
Question 12
What is the priority assessment for a patient who is post-operative following a spinal laminectomy?
A) Pain level
B) Wound drainage
C) Neurological status
D) Bowel sounds
E) Body temperature
Correct Answer: C) Neurological status
Rationale: While all assessments are important, the highest priority after spinal surgery is to
monitor for any changes in neurological function. This includes assessing motor strength,
sensation, and movement in the extremities to detect any potential spinal cord compression
or injury from post-operative edema or hematoma.
Question 13
A patient who is post-operative from a laminectomy has a surgical dressing with a small amount of
clear drainage noted on it. What should the nurse do?
A) Reinforce the dressing and document the finding.
QUESTIONS WITH DETAILED ANSWERS PLUS RATIONALES |MOST
TESTED QUESTIONS AND CORRECT ANSWERS |100% ACCURATE|GET
IT RIGHT!!
Question 1
You are caring for a patient who sustained a basilar skull fracture. The nurse observes clear fluid
draining from the patient's nostrils. Which test should be performed on the fluid to confirm if it is
cerebrospinal fluid (CSF)?
A) Test for protein
B) Test for glucose
C) Test for ketones
D) Test for specific gravity
Correct Answer: B) Test for glucose
Rationale: Cerebrospinal fluid contains glucose, whereas normal nasal secretions do not. The
presence of glucose in the clear drainage is a positive sign that it is CSF and indicates a tear
in the dura mater, which requires immediate physician notification.
Question 2
This image shows a patient with rigid extension of the arms and legs, with the arms pronated and
the feet in plantar flexion. This type of posturing is known as:
A) decorticate
B) decerebrate
C) flaccid
D) opisthotonos
Correct Answer: B) decerebrate
Rationale: Decerebrate posturing is characterized by rigid extension and pronation of the
arms, as well as extension of the legs. It typically indicates more severe damage to the
brainstem.
Question 3
This image shows a patient with abnormal flexion of the upper extremities and extension of the lower
extremities. The arms are adducted and flexed against the chest. This type of posturing is known as:
A) decorticate
B) decerebrate
C) flaccid
D) opisthotonos
Correct Answer: A) decorticate
Rationale: Decorticate posturing is characterized by the arms being flexed, or bent inward on
the chest, with the hands clenched into fists, and the legs extended. It indicates damage to
the cerebral hemispheres, thalamus, or midbrain.
,Question 4
A patient is admitted to the ED after a head injury. They initially lost consciousness, then were alert
and talking for about an hour, and then rapidly lost consciousness again. This clinical presentation is
a classic sign of which condition?
A) Subdural hematoma
B) Subarachnoid hemorrhage
C) Epidural hematoma
D) Ischemic stroke
Correct Answer: C) Epidural hematoma
Rationale: An epidural hematoma, typically caused by an arterial bleed, classically presents
with a "lucid interval." The patient may have an initial loss of consciousness, followed by a
period of being alert, before a rapid decline in neurological status as the hematoma expands
and compresses the brain.
Question 5
What is the primary purpose of a halo fixation device for a patient with a cervical spinal cord injury?
A) To provide traction to the cervical spine
B) To provide rigid immobilization of the cervical spine
C) To assist with ambulation
D) To monitor intracranial pressure
Correct Answer: B) To provide rigid immobilization of the cervical spine
Rationale: A halo fixation device is a type of external brace that completely immobilizes the
head and neck. Its purpose is to stabilize the cervical spine after a severe fracture or surgery
to allow for proper healing and prevent further injury.
Question 6
A patient is being discharged with a halo fixation device. The nurse should educate the patient that
the device will typically be worn for approximately how long?
A) 2-4 weeks
B) 4-6 weeks
C) 8-12 weeks
D) 6-9 months
Correct Answer: C) 8-12 weeks
Rationale: The duration of halo fixation is typically around 8 to 12 weeks to allow for adequate
bone healing and fusion of the cervical spine. The exact duration is determined by the
physician based on follow-up imaging.
Question 7
A patient with a traumatic brain injury is exhibiting Cushing's triad. Which of the following sets of vital
signs is consistent with this condition?
,A) BP 90/60, HR 120, RR 28
B) BP 180/90, HR 50, RR 12 and irregular
C) BP 120/80, HR 75, RR 18
D) BP 90/50, HR 45, RR 10
Correct Answer: B) BP 180/90, HR 50, RR 12 and irregular
Rationale: Cushing's triad is a late, ominous sign of significantly increased intracranial
pressure (ICP). It is characterized by systolic hypertension with a widened pulse pressure,
bradycardia (slow heart rate), and an irregular respiratory pattern.
Question 8
In a patient with increased intracranial pressure (ICP), which ventilator setting can further increase
the ICP and should be used with caution?
A) High PEEP (Positive End-Expiratory Pressure)
B) Low respiratory rate
C) Low tidal volume
D) High FiO2 (Fraction of Inspired Oxygen)
Correct Answer: A) High PEEP (Positive End-Expiratory Pressure)
Rationale: High levels of PEEP can increase intrathoracic pressure, which can impede venous
outflow from the brain. This backup of venous blood can lead to an increase in intracranial
pressure and should be monitored closely in patients with head injuries.
Question 9
You are caring for a patient with increased intracranial pressure (ICP). Which nursing action is most
likely to cause a transient increase in their ICP?
A) Administering a stool softener
B) Keeping the room quiet and dark
C) Suctioning the patient's airway
D) Placing the patient's head in neutral alignment
Correct Answer: C) Suctioning the patient's airway
Rationale: Suctioning can trigger a cough reflex, which significantly increases intrathoracic
and intracranial pressure. While sometimes necessary, suctioning should be performed
quickly and efficiently, and the patient should be hyperoxygenated before and after to
minimize complications.
Question 10
Which of the following represents correct positioning for a patient with increased intracranial
pressure (ICP)?
A) Head of bed flat with knees and hips flexed
B) Head of bed at 30 degrees with the head in neutral alignment
, C) Trendelenburg position to increase cerebral perfusion
D) Side-lying with a pillow between the flexed knees
Correct Answer: B) Head of bed at 30 degrees with the head in neutral alignment
Rationale: Elevating the head of the bed to 30 degrees helps promote venous drainage from
the brain, which can lower ICP. Keeping the head and neck in a neutral, midline position
prevents kinking of the jugular veins and further facilitates venous outflow. Flexion of the
hips and neck should be avoided.
Question 11
What is the mechanism of action of mannitol when administered to a patient with increased
intracranial pressure?
A) It is a loop diuretic that reduces total body fluid.
B) It is an osmotic diuretic that moves fluid from the brain tissue into the blood vessels.
C) It is a corticosteroid that reduces inflammation in the brain.
D) It is a sedative that decreases the metabolic demands of the brain.
E) It is a vasopressor that increases cerebral perfusion pressure.
Correct Answer: B) It is an osmotic diuretic that moves fluid from the brain tissue into the
blood vessels.
Rationale: Mannitol is a large sugar molecule that increases the osmolarity of the blood. This
creates an osmotic gradient that pulls excess water (cerebral edema) out of the brain
parenchyma and into the intravascular space, where it can then be excreted by the kidneys,
thus reducing ICP.
Question 12
What is the priority assessment for a patient who is post-operative following a spinal laminectomy?
A) Pain level
B) Wound drainage
C) Neurological status
D) Bowel sounds
E) Body temperature
Correct Answer: C) Neurological status
Rationale: While all assessments are important, the highest priority after spinal surgery is to
monitor for any changes in neurological function. This includes assessing motor strength,
sensation, and movement in the extremities to detect any potential spinal cord compression
or injury from post-operative edema or hematoma.
Question 13
A patient who is post-operative from a laminectomy has a surgical dressing with a small amount of
clear drainage noted on it. What should the nurse do?
A) Reinforce the dressing and document the finding.
