, NUR 265 Exam 3 (3 Versions) – Medical-Surgical
Nursing –Actual Questions & Answers (GCN)
100% Guarantee Pass
1. A nurse is caring for a client who has suffered a traumatic brain injury (TBI).
Which finding is the earliest indicator of increased intracranial pressure (ICP)?
A. Pupillary changes
B. Decreased level of consciousness
C. Cushing's triad
D. Seizures
Answer: B — Decreased level of consciousness
Rationale: Changes in level of consciousness (LOC) are the earliest and most sensitive
sign of increasing ICP. Without adequate glucose and oxygen, the brain begins to shut
down. Pupillary changes, Cushing's triad, and seizures are later manifestations of
increased ICP and brainstem compression .
2. A client with a traumatic brain injury has an intraventricular drain. The nurse
observes a flat ICP waveform with no respiratory variation and a mean ICP of 5
mm Hg. The patient is sedated and paralyzed. What should the nurse do first?
A. Administer a 500 mL bolus of normal saline
B. Check the drainage system for obstruction or kinking
C. Increase the sedation infusion rate
D. Notify the physician immediately for possible brain death
Answer: B — Check the drainage system for obstruction or kinking
Rationale: A flat waveform with low ICP suggests overdrainage or obstruction. The first
action is to assess the system patency. Saline bolus is not indicated without signs of
hypovolemia. Increasing sedation would lower ICP further. Notifying the physician can
wait until a mechanical issue is ruled out .
,3. A patient with a traumatic brain injury (TBI) is at risk for increased intracranial
pressure (ICP). Which intervention should the nurse implement?
A. Elevate the head of the bed to 30 degrees
B. Keep the neck in a flexed position
C. Suction frequently
D. Administer sedatives as needed
Answer: A — Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of bed 30 degrees promotes venous drainage from the
head and reduces ICP. Neck flexion should be avoided as it can obstruct jugular venous
return. Suctioning increases ICP and should be minimized. Sedatives may be used but
are not the primary intervention .
4. What is the normal range for intracranial pressure (ICP)?
A. 0-5 mmHg
B. 5-15 mmHg
C. 10-20 mmHg
D. 20-30 mmHg
Answer: B — 5-15 mmHg
Rationale: Normal ICP is 5-15 mmHg. Pressures >20 mmHg impair cerebral circulation
and can lead to irreversible brain damage. ICP is a critical parameter in neurological
assessment, as sustained elevation can cause brain herniation and death.
5. The nurse is assessing a client with increased ICP. Which finding is the earliest
indicator of increasing ICP?
A. Cushing's triad
B. Decerebrate posturing
C. Change in level of consciousness
D. Fixed and dilated pupils
Answer: C — Change in level of consciousness
Rationale: Changes in LOC (restlessness, confusion, lethargy) are the earliest and most
, sensitive signs of increasing ICP. Without adequate glucose and oxygen, the brain
begins to shut down. Cushing's triad, posturing, and fixed pupils are late findings
indicating severe brainstem compression.
6. Which nursing intervention is most important for a client with increased ICP?
A. Elevate head of bed 30 degrees
B. Hyperextend the neck
C. Suction frequently
D. Encourage coughing and deep breathing
Answer: A — Elevate head of bed 30 degrees
Rationale: Elevating the head of bed 30 degrees promotes venous drainage and
prevents jugular vein compression. Clustering care should be avoided as it can increase
ICP. Coughing, suctioning, and neck hyperextension all increase ICP.
7. Cushing's triad consists of:
A. Hypotension, tachycardia, tachypnea
B. Hypertension, bradycardia, irregular respirations
C. Hypertension, tachycardia, irregular respirations
D. Hypotension, bradycardia, shallow respirations
Answer: B — Hypertension, bradycardia, irregular respirations
Rationale: Cushing's triad (severe hypertension with widened pulse pressure,
bradycardia, and irregular respirations) is a late sign of increased ICP indicating
brainstem compression and impending herniation.
8. What is the formula for calculating Cerebral Perfusion Pressure (CPP)?
A. CPP = MAP + ICP
B. CPP = MAP - ICP
C. CPP = ICP - MAP
D. CPP = MAP × ICP
Nursing –Actual Questions & Answers (GCN)
100% Guarantee Pass
1. A nurse is caring for a client who has suffered a traumatic brain injury (TBI).
Which finding is the earliest indicator of increased intracranial pressure (ICP)?
A. Pupillary changes
B. Decreased level of consciousness
C. Cushing's triad
D. Seizures
Answer: B — Decreased level of consciousness
Rationale: Changes in level of consciousness (LOC) are the earliest and most sensitive
sign of increasing ICP. Without adequate glucose and oxygen, the brain begins to shut
down. Pupillary changes, Cushing's triad, and seizures are later manifestations of
increased ICP and brainstem compression .
2. A client with a traumatic brain injury has an intraventricular drain. The nurse
observes a flat ICP waveform with no respiratory variation and a mean ICP of 5
mm Hg. The patient is sedated and paralyzed. What should the nurse do first?
A. Administer a 500 mL bolus of normal saline
B. Check the drainage system for obstruction or kinking
C. Increase the sedation infusion rate
D. Notify the physician immediately for possible brain death
Answer: B — Check the drainage system for obstruction or kinking
Rationale: A flat waveform with low ICP suggests overdrainage or obstruction. The first
action is to assess the system patency. Saline bolus is not indicated without signs of
hypovolemia. Increasing sedation would lower ICP further. Notifying the physician can
wait until a mechanical issue is ruled out .
,3. A patient with a traumatic brain injury (TBI) is at risk for increased intracranial
pressure (ICP). Which intervention should the nurse implement?
A. Elevate the head of the bed to 30 degrees
B. Keep the neck in a flexed position
C. Suction frequently
D. Administer sedatives as needed
Answer: A — Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of bed 30 degrees promotes venous drainage from the
head and reduces ICP. Neck flexion should be avoided as it can obstruct jugular venous
return. Suctioning increases ICP and should be minimized. Sedatives may be used but
are not the primary intervention .
4. What is the normal range for intracranial pressure (ICP)?
A. 0-5 mmHg
B. 5-15 mmHg
C. 10-20 mmHg
D. 20-30 mmHg
Answer: B — 5-15 mmHg
Rationale: Normal ICP is 5-15 mmHg. Pressures >20 mmHg impair cerebral circulation
and can lead to irreversible brain damage. ICP is a critical parameter in neurological
assessment, as sustained elevation can cause brain herniation and death.
5. The nurse is assessing a client with increased ICP. Which finding is the earliest
indicator of increasing ICP?
A. Cushing's triad
B. Decerebrate posturing
C. Change in level of consciousness
D. Fixed and dilated pupils
Answer: C — Change in level of consciousness
Rationale: Changes in LOC (restlessness, confusion, lethargy) are the earliest and most
, sensitive signs of increasing ICP. Without adequate glucose and oxygen, the brain
begins to shut down. Cushing's triad, posturing, and fixed pupils are late findings
indicating severe brainstem compression.
6. Which nursing intervention is most important for a client with increased ICP?
A. Elevate head of bed 30 degrees
B. Hyperextend the neck
C. Suction frequently
D. Encourage coughing and deep breathing
Answer: A — Elevate head of bed 30 degrees
Rationale: Elevating the head of bed 30 degrees promotes venous drainage and
prevents jugular vein compression. Clustering care should be avoided as it can increase
ICP. Coughing, suctioning, and neck hyperextension all increase ICP.
7. Cushing's triad consists of:
A. Hypotension, tachycardia, tachypnea
B. Hypertension, bradycardia, irregular respirations
C. Hypertension, tachycardia, irregular respirations
D. Hypotension, bradycardia, shallow respirations
Answer: B — Hypertension, bradycardia, irregular respirations
Rationale: Cushing's triad (severe hypertension with widened pulse pressure,
bradycardia, and irregular respirations) is a late sign of increased ICP indicating
brainstem compression and impending herniation.
8. What is the formula for calculating Cerebral Perfusion Pressure (CPP)?
A. CPP = MAP + ICP
B. CPP = MAP - ICP
C. CPP = ICP - MAP
D. CPP = MAP × ICP
